most commonly impacted tooth is the maxillary canine. If  the patient seeks orthodontic care, the orthodontist will frequently request that the maxillary canine simply have the overlying soft and hard tissue removed so that the  tooth can be manipulated into its proper position byorthodontic appliances. When the tooth is positioned in such a way that orthodontic manipulation can assist the proper positioning of the impacted canine, the tooth is exposed and bracketed (Fig. 9-42, A). A four-corner flap is
created  to allow the soft tissue to be repositioned apically should this be required for maximum keratinized tissue rnuiagement t+Ig. 9-42, B). The overlying bone tissue is then removed with chisel or burs as is-necessary (Fig. 9-42, 0. Once the area is debrided, the surface of the tooth is prepared by the usual standard procedures of etching and applying primer. The bracket is then luted to the surface of thetooth (Fig. 9-42, D). A wire Call be used to connect the bracket to the orthodontic appliance or more commonly a gold chain is attached from the orthodontic bracket to the
orthodontic arch wire. The gold chain provides a greater  degree of flexibility and -the incidence of breakage of thechain ts much less than breakage of a wire. Fhe soh tissue   is then sutured ill such a \\’ay as to provide, the maximum•coverage 01 the exposed tissue with keratinized tissue (fig. 9-42, 1:). A~the tooth is pulled into place with the ortho-,
dontic app liances, the soft tissue surrounding the newlypositioned tooth should have adequate keratinized tissue and the tooth should be in an ideal position.  If the tooth is positioned ‘toward the palatal aspect, the tooth may be either repositioned or removed. f the toothis repositioned, it is surgically exposed and moved into position orthodontically. In this procedure the overlying  is excised; flaps are not needed to gain attached
tissue. Because the bone  in the ‘palate is thicker, a bur isusually necessary to remove the overlying bone. The exposed tooth then is managed in the same manner as is the labially positioned tooth. ‘ If the dentist decides the tooth should be removed, it must be determined if the tooth is positioned labially.toward the palate, or in the middle of the alveolar process. If the t ooth is on the-‘labial aspect, It is easy to reflect a soft tissue flap and to remove the underlying bone and the tooth. However, if the tooth is on the
palatal aspect or in the intermediate buccoiingual position, it is much more difficult to remove. Therefore when assessing the impacted maxillary canine for removalsurgeon’s most important assessment is 01 the buccolin- .gual position of the tooth.   Similar considerations are necessary for other irnpactions, such as mandibular premolars and supernumerary
teeth. The super  tooth in the midline of the  maxilla, called a mesiodens, is almost always found on the palate and should be approached from a palatal direction when it is removed.

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