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Guidelines for the Assessment of the Impacted Maxillary Canine

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Guidelines for the Assessment of the Impacted Maxillary Canine Orthodontics Kate Counihan EA Al-Awadhi and Jonathan Butler Guidelines for the Assessment of the Impacted Maxillary Canine Abstract: Canine impactions are frequently encountered, occurring in 1.7% of the population. The aim of this paper is to provide guidance on the assessment and management of cases which present in general dental practice. Canine position is considered in four categories; canine overlap with adjacent incisor, vertical canine height, angulation to midline and position of canine root apex. Good, average and poor prognostic outcomes are considered for each category and a brief outline of their management is included. Clinical Relevance: Canine impactions frequently present during routine examination. Appropriate recognition, investigation and referral, if necessary, are paramount to successful treatment. Dent Update 2013; 40: 770–777 Treatment of impacted maxillary canines 8% are bilateral.5 The canine has a long arch. Occasionally, canines can be found is a common challenge faced by dental root and good bony support, which is lying horizontally above the apices of the professionals in daily practice. According advantageous in lateral excursions, and maxillary incisors, or displaced near to Mead, an impacted tooth is one that it serves as an excellent abutment for the nose. is prevented from erupting into position fixed and removable prostheses. For because of malposition, lack of space or these reasons, the canine is often referred other impediments.1 After lower third to as the ‘corner stone of the maxillary Aetiology molars, maxillary canines are the most arch’. An absent canine poses aesthetic Buccally and palatally impacted frequently impacted teeth.2 The incidence and functional problems and should be canines have different aetiologies. Jacoby’s of ectopic canine eruption has been shown avoided at all costs. study found that 85% of palatally displaced by Ericson and Kurol to be 1.7%.3 According canines had sufficient space to erupt, to the literature, 85% of canine impactions whereas 83% of buccally impacted canines 4 Development occur palatally and 15% buccally. Impacted had insufficient space to erupt. Therefore maxillary canines have been shown to Canine development crowding was determined as the main occur twice as commonly in females as commences at 4−5 months of age, high aetiological factor in buccal impactions.9 5 males. Dachi and Howell also showed that in the maxilla, lateral to the piriform fossa, Two theories have been proposed to explain the majority of impactions of maxillary and has the longest path of eruption at 22 the aetiology of palatally impacted canines. canines are unilateral at 92%, and only mm.6 Crown calcification starts at 1 year, The guidance theory described by Becker between the roots of the deciduous first et al,10 in 1981, suggests that the distal molar, and is complete at 5−6 years of age. aspect of the lateral incisor is the guide for It then migrates forward and downwards canine eruption. In his study, Becker found Kate Counihan, BDS, MFDS RCS(Ed), to lie buccal and mesial to the apex of that palatally impacted canines were very Specialist Registrar in Orthodontics, the deciduous canine, then continues to closely associated with spaced dentitions EA Al-Awadhi, BDentSc, BA, MSc, PhD, move down the distal aspect of the root and lateral incisors that are peg-shaped, MFD(RCSI), MOrth RCS(Eng), FFD(RCSI), of the upper lateral incisor. As the canine of small mesiodistal width, or congenitally Consultant Orthodontist, Director of erupts into position, the physiological absent. Approximately half of the cases of Teaching and Learning (Postgraduate) median diastema may close.7 Maxillary palatal impactions that were examined were and Jonathan Butler, BDentSc, canines erupt on average at 11−12 years associated with anomalous lateral incisors. MFD(RCSI), MSc, MOrth RCS(Ed), Specialist of age, erupting earlier in females than in The genetic theory described by Peck et Orthodontist, Dublin Dental School and males.8 Canine displacement is classified al,11 in 1994, considers the dental anomaly Hospital, Trinity College, Dublin 2, Ireland. as buccal, palatal, or in the line of the of impacted canines to be a product of 770 DentalUpdate November 2013 Orthodontics polygenetic multifactorial inheritance. They for supervising the eruption of maxillary based their theory on the fact that palatally canines.13 It was found that positive displaced canines are concomitant with palpation indicated a good prognosis for other dental anomalies, such as lateral- eruption and in 92% of cases palpation premolar hypodontia and peg laterals, that was positive. they occur bilaterally and that there is a gender, familial and population difference in occurrence. Other factors documented Radiographic assessment in the multifactorial aetiology for impacted Radiographic examination is canines include: warranted where there is asymmetry on Figure 1. Buccally impacted canine. Presence of supernumeraries; palpation or a pronounced difference Odontomes; in the eruption of canines between left Pathological lesions, eg cysts; and right side is noted. A radiograph may Delayed exfoliation of the deciduous also be wise when the canines cannot canine (although this is thought to be palpated in the normal position and be an indicator rather than a cause of the occlusal development is advanced, or displacement); when the lateral incisor is late erupting or Early trauma to the maxilla; shows a pronounced buccal displacement Cleft lip and palate; or proclination. Radiographic examination Ankylosis; of canine position was only indicated in Figure 2. Palatally impacted canine. Displacement of crypt; 7% of the children in Ericson and Kurol’s Long path of eruption; and group over 10 years of age, according to the Syndromes, eg cleidocranial dysplasia. clinical diagnostic criteria used.13 The canine region should be palpated from the age of 8 years, however, lack of positive palpation is Investigations only considered abnormal at the age of 10 Investigations for unerupted years plus. canines should be carried out clinically and Radiographs are required to radiographically. Clinical assessment will view impacted canines in three dimensions involve visual inspection and palpation. (vertical, mesio-distal and buccopalatal), Radiographic assessment will involve the to view the relationship to the midline Figure 3. Distally inclined lateral in palatal use of parallax or Cone Beam Computerized and adjacent teeth and to evaluate any impaction. Key: yellow and black stripes – palatal Technology (CBCT). resorption.14 The views commonly used position. for assessing ectopic canines include panoramic, periapical, cephalometric, lateral Clinical assessment skull and maxillary occlusal. When localizing Clinical investigation involves impacted canines, two radiographic the following: views are needed to locate the tooth in Visual inspection of the canine bulge, the buccolingual plane.15 The right angle whether it is buccal (Figure 1) or palatal technique uses two radiographs taken (Figure 2), which should be seen between at right angles to each other. This has the lateral incisor and first premolar roots, been done with a lateral cephalometric and inspection of the angulation of the radiograph and a posterior anterior Figure 4. Mesially inclined lateral in buccal lateral incisor, eg a distally inclined lateral radiograph but is not commonly used. impaction. Key: yellow and black boxes – buccal incisor may infer palatal impaction (Figure The most common means of radiographic position. 3) and a mesially inclined lateral incisor localization currently in use are parallax may indicate buccal impaction (Figure 4). and CBCT. In addition, the colour and mobility of the The preferred means of deciduous canine should be inspected as localization is parallax, which is the this might indicate resorption of the root. apparent displacement of an image Palpation of the buccal surface of relative to the image of a reference object the alveolar process distal to the lateral and is caused by an actual change in incisor from 8 years of age may reveal the the angulation of the X-ray beam.16 The position of the maxillary canine and has reference object is normally the root of an been recommended as a diagnostic tool adjacent tooth. The image of the tooth that by Kettle.12 A longitudinal study of 505 is farther away from the X-ray tube moves Figure 5. Resorption area on radiograph and clinically on extracted tooth. school children evaluated clinical methods in the same direction as the tube, whereas November 2013 DentalUpdate 771 Orthodontics that of the tooth closer to the X-ray tube superimposition of the incisor roots and the with physical contact between the root of moves in the opposite direction to the crown of the impacted canine obscuring the incisor and prominences on the canine tube (SLOB Rule − Same Lingual Opposite morphology. CBCT overcomes this problem, crown (Figure 5).30 However, the response Buccal). An orthopantomogram (OPG) and increasing detection of resorption by 50%.25 of incisors with resorbed roots following anterior occlusal radiograph are commonly CBCT eliminates potential problems with treatment of impacted canines was used, giving a 60° tube shift approximately. magnification and superimposition which assessed by Becker and Chaushu31 and they This is vertical parallax, as the angulation make interpretation and localization with suggested that, once the impacted canine of the X-ray beam changes in the vertical conventional
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