Retained deciduous canines, a high labial canine and a mother who wants everything fixed now

Priority order:

1. Potentially impacted 13 and 23 (high labial 13, retained 53/63). This is the problem with a time-limited window: once root formation of the canine is complete and the space is lost, spontaneous eruption becomes unlikely and surgical exposure plus orthodontic traction may be needed. It is the only genuinely urgent item.
2. Crowding (6 mm upper, 4 mm lower) in the mixed dentition. Some of this will resolve as the leeway space is used during the transition to the second permanent molars; 6 mm in the upper arch is borderline rather than automatically requiring extraction of premolars.
3. 6 mm overjet with incompetent lips. Aesthetic and soft-tissue issue, and carries a small trauma risk to the incisors, but there is no evidence that early treatment of a 6 mm overjet changes the final outcome.

What I would do now:

• Extract the retained 53 and 63. They are firm, the permanent successors are displaced and the deciduous teeth are physically obstructing eruption. Removal is low-risk and removes one obstacle.
• Do not extract permanent teeth at 9. Any premolar extraction decision belongs in the late mixed or early permanent dentition, once the incisor relationship and arch length requirements are known.
• Radiographic and clinical review in 6-12 months, checking whether 13/23 descend and whether the 13 becomes palpable.
• Record the overjet and lip competence, reinforce the stopped habit, and give caries prevention - the patient is at the age where first permanent molars erupt and sealants are relevant.
• Refer for an orthodontic assessment rather than starting treatment in general practice, but make the referral informative: the reason is canine position, not crowding.

Clinical triggers:

• 13 or 23 still not palpable 6-12 months after removal of the deciduous canines, or the 13 becoming more superiorly and palatally/laBially positioned rather than descending.
• Asymmetry between the two sides that is worsening.
• Mobility, discolouration or increased pocketing of 12 or 22, which suggests root resorption by the erupting canine - any suspicion is an indication for imaging.

Radiographic triggers:

• Increasing overlap of the canine crown on the incisor root, or any sign of root resorption.
• Continued lack of eruption with completed root formation and no space.

Imaging: a periapical or upper standard occlusal can localise the canine in two planes; CBCT is justified when there is suspected incisor root resorption, when surgical exposure is being planned, or when the canine's position cannot be established by conventional films. It should not be used as a routine screening tool in a 9-year-old.

Surgical/orthodontic intervention:

• Surgical exposure with an attachment and orthodontic traction, or surgical exposure with spontaneous eruption if the canine is superficial and there is space.
• Creation of space by expansion or, in a crowded arch, extraction - usually of premolars, decided late.
• If the canine is ankylosed or severely displaced and cannot be brought into the arch, extraction and substitution by the first premolar is a valid option that must be discussed early enough for the occlusion to be planned around it.

This is the point to make to the mother: the decision about the canine drives everything else.

What I would say:

• There are two separate questions here: getting the adult canine down, and straightening the teeth overall. The first needs action now-ish; the second does not.
• Removing the two baby canines is a small intervention that may let the adult canines come down on their own. It sometimes works and sometimes does not - the evidence that it reliably prevents impaction is weak, and the Cochrane review found insufficient reliable evidence that removing the deciduous canine prevents a palatally displaced canine from becoming impacted. It is still worth doing because it removes an obstruction, carries little risk, and is not harmful.
• Early braces for the overjet and crowding does not shorten or avoid later treatment. Trials of early (two-phase) treatment of Class II problems found that children treated early are no more likely to avoid a second phase, and the total time in treatment is similar or longer. Early treatment may have a place for very large overjets (roughly 9-10 mm and above) where the risk of incisor trauma is significant - at 6 mm with incompetent lips that threshold is not met, though the lips should be watched.
• So the plan is: remove the baby canines, watch and check in 6-12 months, and plan definitive orthodontic treatment when the permanent dentition is more complete, around 11-13 years, when the canine position and the space requirements are clearer.
• Set expectations honestly: there may be a phase of treatment now and more later, but the later phase is not caused by waiting - it is the definitive treatment.

Also cover: what happens if the canines do not come down (exposure and pulling them into place, or, rarely, removal and substitution), the cost and time implications of each, and the importance of good cleaning and prevention while appliances are considered.