# Orthodontic Surgical Treatment of Impacted Mandibular Canines: Systematic Review and Case Report
## 4 Case Report  
The patient was an 11.5-year-old child undergoing orthodontic treatment. He presented with mixed dentition, Angle Class I dental relationship of the permanent dentition with a 1 mm overjet, centered midlines, and slight crowding in both arches. All clinical documentation--consisting of impressions and study models (Figure 4), Rx OPT (Figure 5), lateral cranial Rx (Figure 6), and cephalometric analysis (Figure 7, Table 4)--was collected for case evaluation and subsequent treatment. \begin{table}
\begin{tabular}{l c c c c} \hline \hline
**Dental Reports** & & & & \\ \hline
**Measure** & **Value** & **Mean** & **Deviation** & **Measurement Analysis** \\ \hline Molar report (A6-B6) \(-1\), N & \(-1.6\) & \(-3\pm 3\) & N & Class I dental \\ \hline Overjet (B1-A1 Horz.) & 1.8 & \(2.5\pm 2.5\) & N & Normal \\ \hline Overbite (B1-A1 Vert.) & 0.2 & \(2.5\pm 2.5\) & N & Normal \\ \hline Inferior incisor extrusion (B1-Ocl.) & 0.5 & \(1.25\pm 2\) & N & Normal \\ \hline Angolo Interincisivo (A1-B1 angle) & 118.2 & \(132\pm 6\) & -XX & \\ \hline G02—Skeletal Reports & & & & \\ \hline Convexity (A-NPog) & 4.8 & \(1\pm 2\) & X & Class II bone \\ \hline Lower face height (ANS-Xi-Pm) & \(47.9^{\circ}\) & \(47\pm 4\) & N & Facial meso \\ \hline Dentoskeletal Ratios & & & & \\ \hline Upper molar position & 12.1 & \(17\pm 3\) & -X & Class III \\ \hline Inferior incisor protrusion (B1-APog) & 3.7 & \(1\pm 2.3\) & X & Protrusion \\ \hline Superior incisor protrusion (A1-APog) & 5.5 & \(3.5\pm 2.3\) & N & Normal \\ \hline Lower incisor inclination & \(30.5^{\circ}\) & \(22\pm 4\) & XX & \\ \hline Upper incisor inclination & \(31.3^{\circ}\) & \(28\pm 4\) & N & Normal \\ \hline Occlusal plane inclination & \(19.9^{\circ}\) & \(24.5\pm 4\) & -X & \\ \hline Craniofacial Reports & & & & \\ \hline Facial depth (PoOr-NPog) & \(81.7^{\circ}\) & \(88.5\pm 3\) & -XX & Facial dolic \\ \hline Facial axis (BaN-PTGn) & \(86.5^{\circ}\) & \(90\pm 3\) & -X & Facial dolic \\ \hline With facial iscity & \(68.4^{\circ}\) & \(68\pm 3.5\) & N & Facial meso \\ \hline Mandibular plane angle (GocMe-P) & \(29.9^{\circ}\) & \(24.5\pm 4\) & X & Facial dolic \\ \hline Jaw depth (PoOr-NA) & \(86.8^{\circ}\) & \(90\pm 3\) & -X & Retrographia \\ \hline Palatal floor (PoOr-ANSPNS) & \(0.3^{\circ}\) & \(1\pm 3.5\) & N & \\ \hline \hline \end{tabular}
\end{table} 
Table 4: Cephalometric analysis results. Figure 7: Cephalometric analysis. After one year of interceptive therapy, a control Rx OPT was performed to assess the status of the tooth permutation (Figure 8). The Rx OPT showed the intraosseous inclusion with mesio angulation of the 4.3 element. IMC was assessed according to [PERSON]'s classification [5], which describes five types of transmigrated mandibular canine (Figure 1). The clinical case described in this article concerns type number 1. CBCT was performed to assess the position of the IMC in relation to the surrounding anatomical structures (Figure 9). The CBCT showed part of the crown of the IMC (4.3) in contact with the root apices of the right lower incisors. (4.1 and 4.2). All of this diagnostic information allowed us to choose between the following treatment options:  
- Interceptive treatment, including the extraction of a primary canine or the opening of an orthodontic space with fixed appliances [29];  
- Orthodontic extrusion of 4.3 [26];  
- Transalveolar transplantation of 4.3 [30];  
- Avulsion of 4.3 [31]. The positional factors that influenced the decision to surgically remove or surgically expose the IMC were considered. These included the following:  
1. Canine angle to the midline;
2. Horizontal position of the canine root apex;
3. Vertical height of the canine crown;
4. Canine overlap of adjacent tooth;
5. Buccal-lingual position of the canine. After explaining the clinical situation and the possible therapeutic solutions to the parents and the young patient, it was decided, after obtaining the informed consent of the parents, to recover the included element (4.3) through a combined orthodontic-surgical approach.