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. 2025 Dec 8;25:1885. doi: 10.1186/s12903-025-06824-3

A digitally designed and 3D-printed customized device for the three-dimensional traction of complex maxillary impacted canines: case reports

Yuelin Yu 1,2,#, Yunchen Zha 1,#, Siya Zhu 2,#, Shushu Li 1, Penglin Wang 1, Jing Qiao 2, Weidong Kong 1,✉
PMCID: PMC12683821  PMID: 41361269

Abstract

Background

The traction of an impacted canine is complicated and challenging due to its position, direction, relationship to adjacent teeth and anchorage design. This study describes a customized device for the three-dimensional traction of complex maxillary impacted canines (MICs).

Case presentation

This article reports two cases of young patients with complex MICs (Case Ⅰ: the MIC has high horizontal impaction without enough adjacent anchorage teeth, and Case II: the crown of the MIC is entirely embedded between the roots of adjacent incisors). A digitally customized device was developed to optimally resolve impaction management challenge in both patients. The therapeutic effects are evaluated by comparing the pretreatment, during-treatment and posttreatment results, including those from clinical and imaging examinations. After traction using the customized device, the impacted canines were successfully repositioned in the dental arch, and both the anchoring teeth and adjacent teeth were in good condition, which established a robust foundation for subsequent stage. Then, after fixed orthodontic treatment, both patients exhibited good dental alignment.

Conclusions

The satisfactory clinical outcome demonstrated that the customized device is convenient, comfortable, safe, and excellent in 3D control for the traction of MIC; in conjunction with fixed orthodontic techniques, it can effectively accomplish comprehensive orthodontic treatment for MIC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06824-3.

Keywords: Impacted canines, Customized device, Orthodontic treatment, 3D printing

Introduction

Impacted teeth are affected by multiple factors, surpassing the eruption phase while remaining unerupted in the mucosa or bone [1]. The prevalence of MIC varies between 1.0% and 2.5% [2], second only to the third molar [3]. The occurrence of MIC is associated with several factors, including congenital conditions (such as skull-clavicle dysplasia syndrome and primary failure of tooth eruption (PFE)), local environmental influences (such as chronic apical periodontitis, dental trauma, supernumerary teeth, or odontoma), and genetic factors [4]. MIC can affect pronunciation and mastication and may also cause dental cysts, leading to local alveolar bone developmental anomalies and ultimately influencing facial appearance and even mental health [5]. Moreover, an MIC of approximately 44.5% may cause adjacent lateral incisor root resorption [6, 7].

The diagnosis of MIC is relatively clear. Orthodontists can perform thorough assessments on the basis of the physiological replacement of permanent teeth, retention of deciduous teeth, and imaging examinations [3]. Due to the detrimental effects of MICs, early treatment has improved the clinical value [4, 8]. At present, the following methods are available to address MIC: (1) surgical exposure of the MIC and orthodontic traction into the dental arch [9]; (2) replanting the MIC to an appropriate place [10]; and (3) extracting the MIC and maintaining space for restoration [11]. Basen on the importance of canines in terms of function and aesthetics, preserving them to the greatest extent possible is essential. With the exception of MICs influenced by specific factors (such as isolated ankylosis or PFE) that show no response to orthodontic traction [12, 13], other MICs can be effectively treated using orthodontic methods.

Fixed appliances are a common method for treating MIC [14]. However, the position and orientation of MICs are intricate [3, 15]. For example, MICs exhibiting horizontal high impaction or complex interconnections with adjacent teeth pose challenges for fixed appliances. Blind traction is harmful to adjacent teeth, leading to the extraction of MICs under these circumstances [9].

Furthermore, some young patients with mixed dentition have inadequate clinical crown height or premature tooth loss, making existing orthodontic appliances difficult for the traction mechanics of MIC due to the deficiency of anchor teeth [16–19]. In this report, we present a customized device suitable for the traction of poor anchorage conditions in patients with MICs.

The device is digitally designed and 3D-printed using information acquired by intraoral scanning and cone beam computed tomography (CBCT), typically comprising four steps: (1) a proper traction pathway for the MIC is designed based on its position, direction and relationship to adjacent teeth; (2) the ideal position and length of the traction arm and hook for the device are designed based on the resistance and rotation centres of the MIC; (3) a combination design of anchorages, retainers, and connectors; and (4) the use of 3D-printing technology to manufacture customized devices.

Case presentations

We report in detail the design of a customized device and orthodontic treatment of two adolescent patients with complex MICs.

Case Ⅰ

Patient I, a 10-year-old male, presented with delayed eruption of the left upper canine and was brought to the First Affiliated Hospital of Jinan University by his parents. He exhibited good physical health and denied poor oral habits, a history of trauma, orthodontic treatment, familial disease, systemic illness, and allergies.

The patient presented a straight profile (Supplementary Fig. 1). Intraoral examination (Fig. 1A-F) revealed that the upper left canine had not erupted. The patient had mixed dentition with a molar class II relationship. The mandibular midline was displaced 3 mm to the left. The upper left lateral incisor exhibited palatal displacement.​​ Panoramic imaging (Fig. 2A) revealed that the upper left canine had high horizontal impaction, with a congenital deficit of the upper right and left first premolars. The axial-vertex view (Fig. 3B) derived from the CBCT images revealed the impacted canine medial crown position in sector 3 [20]. Sagittal plane images (Fig. 3A, C) revealed that the impacted canine (#23) displaced the root of the adjacent incisor (#22) towards the palatal side. According to Nolla’s stages of root development [21], apical closure of the impacted canine (#23) was completed (Fig. 3D), suggesting that root formation occurred at the Nolla 10 stage. Following discussions with his parents, we attempted to use the customized device for stage Ⅰ orthodontic traction of the impacted canine (#23), followed by stage II alignment.

Fig. 1.

Fig. 1

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Pretreatment intraoral photographs (patient I). A Right lateral intraoral view, B Frontal intraoral view, C Left lateral intraoral view (#23 had not erupted, and #22 exhibited palatal ectopia with torsion), D Upper occlusal intraoral view, E Front teeth overjet view, F lower occlusal intraoral view

Fig. 2.

Fig. 2

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Pre- and during-treatment panoramic images (patient Ⅰ). A High horizontal impaction of the upper left canine (yellow arrow), B After 12 months of traction, #23 was successfully repositioned with a counterclockwise rotation of 90°

Fig. 3.

Fig. 3

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Pre- and in-treatment CBCT images (patient Ⅰ). A-C Pretreatment, #23 had high horizontal impaction, causing the root of #22 to be displaced towards the palatal side. D Pretreatment, #23 root formation occurred at the Nolla 10 stage. E-F After 12 months of traction, #23 was separated from the roots of #22

Treatment procedure

Design of customized device

The upper right and left first molars, upper right lateral incisor, and Nance appliance were configured as anchors connected by a palatine rod (Fig. 4A-B). Considering the relationship of the adjacent teeth (#22 and #25) with the impacted canine (#23), along with the resistance and rotation centres of the impacted canine (#23), we designed a traction arm in the distal direction equipped with two traction hooks. Furthermore, we designed another traction arm in the occlusal direction equipped with a traction hook (Fig. 4 C).

Fig. 4.

Fig. 4

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Digital structure and traction simulation design of the customized device (Case Ⅰ). A-B #16, #26, #12, and the Nance arch in the anterior hard palate were configured as anchors connected by a palatine rod. C Three traction hooks in the distal and occlusal directions. D a and b: traction arms; arm “a” (distally directed): Two hooks for counterclockwise rotation and angulation correction, arm “b” (occlusally directed): One hook for vertical eruption. 1, 2 and 3: traction hooks. The forces (F1, F2) delivered to the canine through the power chain and the device, and the corresponding moments (M1, M2) differ due to the varied relationships between the force application point and the centre of resistance (CR) of the canine

Traction design (Fig. 4D): Traction hooks “1” and “2” on arm “a” facilitated the counterclockwise rotation of the impacted canine (#23) and adjusted the eruption direction. Subsequently, traction hook “3” on arm “b” was used to move the impacted canine (#23) towards the occlusal plane.

Clinical application of customized devices

After the customized Clinical application of customized device was bonded, the crown of the impacted canine (#23) was exposed via surgical fenestration, and the lingual buckle was attached to the surface. The power chain was connected to the lingual buckle and hung from the traction hooks on the “a” arm (Fig. 5A-D), with monthly replacements of the power chain, to rotate #23 clockwise and adjust the eruption orientation of the impacted canine (#23). After eight months of traction, the impacted canine (#23) exhibited a counterclockwise rotation effect (Supplementary Fig. 2). Ten months later, intraoral examination (Fig. 5E-H) revealed that the impacted canine (#23) was oriented vertically, with a portion of the crown protruding through the alveolar mucosa. The power chain was subsequently altered to traction hooks on arm “b,” and the canine (#23) was subsequently adjusted to the occlusal plane.

Fig. 5.

Fig. 5

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During treatment, intraoral photographs (patient I) were taken. A-D At the start of traction, #23 was extracted using arm “a”. E-H After 10 months of traction, #23 was oriented vertically, with a portion of the crown protruding through the alveolar mucosa. The traction arm then changed to arm “b”. I-L After 12 months of traction, #23 was in satisfactory condition

Treatment results

After 12 months, the crown of the impacted canine (#23) was in satisfactory condition, and the customized device was removed (Fig. 5I-L). Clinical examinations revealed that no substantial alterations occurred in the anchorage teeth or adjacent teeth, and both the tooth mobility assessment and pulp vitality test yielded optimal results. The panoramic image (Fig. 2B) revealed that the impacted canine (#23) was vertical with a counterclockwise rotation of 90°. CBCT images (Fig. 3E-F) revealed that the impacted canine (#23) was separated from the roots of the adjacent incisor (#22). A fixed appliance was subsequently used to align the teeth. The lower left and lower right first premolars were removed to alleviate crowding and achieve proportional harmony between the upper and lower dental arches. After 28 months of treatment, the patient achieved ideal tooth alignment (Fig. 6A-F). The profile was ideal (Supplementary Fig. 3).

Fig. 6.

Fig. 6

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Post stage II fixed orthodontic treatment intraoral photographs (Patient I). A right lateral intraoral view, B frontal intraoral view, C left lateral intraoral view, D upper occlusal intraoral view, E front teeth overjet view, F lower occlusal intraoral view

Case II

Patient II was a 13-year-old male with irregular upper dentition who visited the First Affiliated Hospital of Jinan University with his parents. The patient denied detrimental oral habits, a family history of illness, systemic conditions, and allergies.

The patient presented an average growth pattern (Supplementary Fig. 4). Intraoral examination (Fig. 7A-F) revealed that the upper left deciduous canine was retained and that the upper left canine exhibited no eruption. The right molar was class I relationship and left molar was class III relationship. A moderately deep overbite and class II deep overjet were present. The maxillary midline was displaced 2 mm to the right and 3 mm to the left of the lower midline. The upper left lateral incisor had a significant labial inclination. The panoramic radiograph (Fig. 8A) revealed impaction of the upper left canine, with the crown mesially inclined at approximately 45°. Cone beam CT (CBCT) (Fig. 9A) revealed that the crown of the impacted canine (#23) was entirely embedded between the roots of the upper left incisors. The axial-vertex view (Fig. 9B) derived from the CBCT images revealed the position of the impacted canine medial crown in sector 4, according to the classification methods proposed of Ericson S, Kurol J [20]. According to the Nolla staging, the apical closure of the impacted canine (#23) was completed (Fig. 9C), suggesting that root formation occurred at the Nolla 10 stage. Based on the intricate condition of the impacted canine (#23) and following discussions with the child’s parents, we attempted to use a customized device for stage I orthodontic traction, followed by stage II alignment.

Fig. 7.

Fig. 7

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Pretreatment intraoral photographs (Case II). A Right lateral intraoral view, B Frontal intraoral view, C Left lateral intraoral view (#63 was retained and #23 exhibited no eruption, #22 had a significant labial inclination), D Upper occlusal intraoral view, E Front teeth overjet view, F Lower occlusal intraoral view

Fig. 8.

Fig. 8

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Pre, during, and posttreatment panoramic radiographs (Case II). A Pretreatment: #23 mesial impaction, with a crown inclination of approximately 45° (yellow arrow). B During treatment, after 14 months of traction, #23 was positioned satisfactorily, and malformed #12 and #22 were extracted to alleviate crowding. C Posttreatment: Following two years of fixed orthodontic treatment, ideal tooth alignment was achieved, and the degree of root parallelism was satisfactory

Fig. 9.

Fig. 9

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Pre- and during-treatment CBCT images (Case II). A-B Pretreatment, the crown of #23 is completely embedded between the roots of #21 and #22. C Pretreatment, Nolla stage 10 root formation of #23. D-E After 8 months of traction, #23 exhibited “reverse movement,” detached from the roots of #21 and #22

Treatment procedure

Design of customized device

The upper right and left first molars and the upper left first premolar were designed as anchors interconnected by a palatine rod (Fig. 10A). Due to the intricate relationships of the upper left incisors and the impacted canine (#23) with the resistance and rotation centres of the impacted canine (#23), we designed a traction arm situated above the cutting margin of the canine (#23) and equipped it with five micro traction hooks. Furthermore, we designed another traction arm on the occlusal aspect of the canine (#23), which was equipped with two micro traction hooks (Fig. 10B).

Fig. 10.

Fig. 10

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Digital structure and traction simulation design of the customized device (Case II). A #16, #26, and #24 were designed as anchors interconnected by a palatine rod. B-C A traction arm situated above the cutting margin of #23, another traction arm on the occlusal aspect of #23. D a and b: traction arms; arm “a” (supra-incisal): Five micro-hooks for apical/distal movement ("reverse movement") and angulation control, arm “b” (occlusal): Two micro-hooks for vertical eruption. 1, 2, 3, 4, 5, 6 and 7: traction hooks. The forces (F1, F2, F3) delivered to the canine through the power chain and the device, and the corresponding moments (M1, M2, M3) differ because of the varied relationships between the force application point and the centre of resistance (CR) of the canine

Traction design (Fig. 10D): Traction hooks “1” and “2” on arm “a” were used to move the impacted canine (#23) apically and distally, similar to "reverse movement, "achieving separation from the upper left incisors. Traction hooks “3,” “4,” and “5” on arm “a” were subsequently used to adjust the eruption direction of the impacted canine (#23). Finally, traction hooks “6” and “7” on arm “b” were used to move the impacted canine (#23) towards the occlusion plane.

Treatment results

After 14 months of traction, the crown of the upper left canine exhibited satisfactory conditions (Fig. 11B-C). It was evident that the impacted canine (#23) was able to move. Based on the importance of the canine in terms of occlusion and aesthetics, we chose to preserve it. The malformed upper right and left lateral incisors were extracted to alleviate crowding for stage II alignment. The customized device was removed. Clinical examinations revealed that no substantial alterations occurred in the anchorage teeth or adjacent teeth, and both the tooth mobility assessment and pulp vitality test yielded optimal results. The panoramic image (Fig. 8B) indicated that the impacted canine (#23) was separated from the root of the adjacent central incisor (#21), and there was no resorption present in the roots. The intraoral examination (Fig. 11D) revealed that the mandibular dental arch was constricted and that the lower left second premolar was congenitally absent. Therefore, in stage II orthodontic treatment, the mandibular teeth were not extracted to match the width of the upper and lower dental arches. After two years of fixed orthodontic treatment, intraoral photographs (Fig. 12A-F) revealed that ideal tooth alignment was achieved. The morphology and periodontal status of the upper left canine closely resembled those of the contralateral canine. The upper canines could be treated in adulthood to restore aesthetics. The degree of root parallelism was satisfactory (Fig. 8C). The profile was optimal (Supplementary Fig. 5).

Fig. 11.

Fig. 11

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During treatment, intraoral photographs (Patient II) were taken. A After 10 months of traction, the protrusion of the apex of the left maxillary canine (yellow arrow) occurred. B-C After 14 months of traction, the crown of #23 exhibited satisfactory conditions, and malformed #12 and #22 were extracted to alleviate crowding for stage II alignment. D The mandibular dental arch was constricted, and #35 was congenitally absent

Fig. 12.

Fig. 12

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Posttreatment intraoral photographs (Patient II). A Right lateral intraoral view, B Frontal intraoral view, C Left lateral intraoral view, D Upper occlusal intraoral view, E Front teeth overjet view, F Lower occlusal intraoral view

Discussion

MICs are common in young orthodontic patients [22]. Early intervention is critical to mitigate aesthetic, functional, and psychological impacts lead by MICs [4, 23, 24]. However, conventional traction methods have some limitations in anchorage strategies and traction force application. The customized device proposed in this study has certain advantages in the use of digital design and 3D printing technology to achieve flexible anchorage strategies and accurate three-dimensional force application.

Limitations of conventional traction methods

Conventional traction of MIC often uses fixed appliances [25]. Nevertheless, this method is more appropriate for impacted canines with adjacent teeth that are positioned mesially and distally and can serve as anchors. The traction force originates primarily from the primary or auxiliary archwire, and its direction is relatively straightforward. It is typically used to treat MIC when the crown-root orientation aligns with the eruption trajectory (such as in high vertical impact). When the position and orientation of the MIC are more intricate, such as being positioned deeper, exhibiting a greater crown-root inclination angle, or being horizontal, along with a complicated relationship with adjacent teeth, repositioning them using solely fixed appliances becomes challenging. In such instances, specialized appliances, such as cantilevers that facilitate traction, are frequently added in conjunction with a transpalatal arch (TPA) to enhance anchorage [14, 26, 27]. However, prior reports indicate that such specialized appliances are predominantly fabricated through manual bending or mechanical welding [27]. The constraints of the manufacturing process occasionally hinder the precision of three-dimensional control in the traction process, resulting in failure to satisfy clinical requirements and ultimately leading to traction failure [9]. In addition, some scholars have found that TPA device may cause a certain degree of molar anchorage loss during orthodontic traction [28].

Advantages of customized anchorage strategies

Patient Ⅰ described in this report presents a challenging highly horizontally impacted canine. The possibility of a natural eruption of the impacted canine (#23) was relatively low, based on the eruption’s trajectory. However, congenital absence of maxillary first premolars (#14 and #24) and delayed eruption of second premolars (#15 and #25) in this mixed dentition patient made fixed appliance challenging due to the lack of anchorage. Therefore, we digitally designed a customized device to enhance anchorage control for the traction of the impacted canine. We chose the upper right and left first molars, which possessed the largest periodontal membrane area and exhibited the most stable position post eruption, as primary anchorage teeth, designed a Nance button on the hard palate, and interconnected these with a palatal rod to establish a stable triangular anchorage structure. Moreover, the upper right lateral incisor was selected as an extra anchorage tooth to improve device stability. This new device successfully addresses the challenge of designing appropriate anchorages with fixed appliances. In addition, the surfaces of the crowns of the anchorage teeth (#16, #26, and #12) were designed as bondable, customizable bases, thereby obviating the necessity for band fabrication, streamlining clinical processes, and improving patient comfort. Clinical outcomes indicated that this device successfully repositions the impacted canine (#23) along the simulated eruption path. A labial orthodontic appliance was subsequently used to achieve proper alignment.

Advantages of three-dimensional force application

In patient II, the patient’s condition was also quite complex. The crown of the MIC (#23) was entirely embedded between the roots of the adjacent incisors (#21 and #22), and the crown and part of the root of the impacted canine (#23) were ectopic in relation to the upper left lateral incisor. The use of conventional fixed orthodontic appliances to reposition the canine and the lateral incisor (#23 and #22) was exceedingly challenging. Therefore, we incorporated CBCT to assess the relationship of the upper left incisors and the impacted canine (#23) and the centre of resistance and the centre of rotation of the impacted canine (#23). Accordingly, we designed customized traction arms and hooks to reposition the impacted canine (#23), addressing the limitations of existing devices in providing precise three-dimensional traction for impacted canines. Clinical outcomes demonstrated that this device allowed the impacted canine (#23) to move distally and apically to effectively disengage it from the interlocked relationship with adjacent tooth roots, accomplishing complex “reverse movement.” Then device also adjusted the eruption orientation of the impacted canine (#23), and a labial orthodontic appliance was used to achieve proper alignment.

Safety of full-cycle therapeutic management‌

MIC is generally a component of overall malocclusion [15, 29, 30]. Some patients require extraction to achieve optimal orthodontic treatment outcomes. Considering the significance of canine aesthetics and functionality, treatment protocols should prioritize the preservation of the MIC [31]. However, achieving traction is a challenge for orthodontists [32]. Some MICs may not respond to traction due to inadequate anchoring, improper force application, or possible ankylosis (such as primary failure of eruption (PFE) or isolated ankylosis) [13, 33]. Extracting the adjacent premolar without verifying whether the MIC is moveable has certain dangers [34]. If it is verified that the MIC can move prior to the extraction of adjacent teeth, the viability and safety of the treatment plan would be inherently enhanced. Considering these factors, the upper left lateral incisor was recognized as a microdontia in Patient II, and the treatment plan included the extraction of the upper left lateral incisor and its replacement with the impacted canine (#23). For safety reasons, the upper left lateral incisor was not extracted at the start of therapy. A customized device was used to verify that the impacted canine (#23) could be effectively moved prior to extraction. This procedure allowed for the eruption of the impacted canine and provided a “therapeutic diagnostic” technique to assess the movable potential of the impacted canine clinically, guaranteeing the secure and effective execution of the treatment plan.

Conclusions

This digitally designed and 3D-printed customized device provides accurate 3D control, flexible anchorage, and enhanced comfort for intricate traction of MICs. In conjunction with fixed orthodontic techniques, it can effectively accomplish comprehensive orthodontic treatment for challenging MICs, while minimizing iatrogenic risks.

Supplementary Information

Supplementary material 1. (419.5KB, docx)

Acknowledgements

The authors thank Riton Biomaterial Co., Ltd. (Guangzhou, China) for the 3D printing of the customized devices.

Abbreviations

MIC

Maxillary impacted canine

PFE

Primary failure of eruption

CR

Centre of resistance

TPA

Transpalatal arch

Authors’ contributions

YYL and ZYC drafted the manuscript. YYL, ZSY, QJ, and WPL—collected and analysed the data. KWD—designed the device and revised the manuscript. All authors have read and agreed to the published version of the final manuscript.

Funding

This research was funded by the Science and Technology Program Project of Guangzhou, China (No. 2023A03J1029).

Data availability

The data presented in this study are available upon reasonable request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Jinan University in China (ref: JUNKY-2022-0146). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from the patients and their legal guardians.

Consent for publication

Written informed consent was obtained from the patients and their legal guardians for publication of this case report and images.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Yuelin Yu, Yunchen Zha and Siya Zhu contributed equally to this work.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary material 1. (419.5KB, docx)

Data Availability Statement

The data presented in this study are available upon reasonable request from the corresponding author.

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