IJCDC

RADIOGRAPHIC LOCALIZATION OF IMPACTED

MAXILLARY PERMANENT CANINES:
COMPARISON OF TWO TECHNIQUES

JAN - JUNE 2012 VOL 2 ISSUE 1

Indian Journal
of Comprehensive
Dental Care
1. Kawar Randhawa
2. Preeti Chawla
3. Ramandeep S Narang
4. Adesh Manchanda

ABSTRACT
Background: Exact localization and early detection of impacted
maxillary canine is necessary for interceptive treatment to reduce the
need for more complex surgical and orthodontic intervention. The
objective of localization is selection of a suitable technique which has
minimal radiation dose, cost and maximum details.
Aims: To evaluate the reliability of a single panoramic radiograph in
locating the position of impacted maxillary canines. To compare two
different radiographic techniques for localization of impacted maxillary
canines: two periapical views using Clark's rule and single panoramic
radiograph using technique suggested by Katsnelson et al.

1. Senior Lecturer, Department of Oral Medicine, Diagnosis and

Radiology, Sri Guru Ram Das Institute of Dental Sciences and
Research, Amritsar.
2. Reader, Department of Oral Medicine, Diagnosis and
Radiology, Sri Guru Ram Das Institute of Dental Sciences and
Research, Amritsar.
3. Associate Professor, Department of Oral Pathology and
Microbiology, Sri Guru Ram Das Institute of Dental Sciences
and Research, Amritsar.
4. Senior Lecturer, Department of Oral Pathology and
Microbiology, Sri Guru Ram Das Institute of Dental Sciences
and Research, Amritsar.

Materials and methods: The inclination of the impacted maxillary

canine to a horizontal line from the mesiobuccal cusps of the maxillary
molars was measured on a panoramic radiograph. These
measurements were used to predict the position of the tooth and
compared with results of Clark's rule.
Results: The mean angulation of buccally impacted canines was 64.1o
o
o
o
(range 40 to 95 ) and in the palatally impacted canines was 50.2 (range
o
o
14.5 to 84 ). The location of impacted maxillary canine as measured on
the panoramic radiograph was statistically significant.
Conclusion: Panoramic radiographs are useful for predicting the
location of impacted maxillary canines when computed tomography is
unavailable or unnecessary otherwise.
Key words : impacted maxillary canines, panoramic radiograph,
canine localization.

INTRODUCTION
Maxillary canines are the second most impacted teeth after
third molars with a prevalence ranging from approximately
1% to 3%.1,2,3 Maxillary canine impaction is twice as common
in females as it is in males.4 The incidence of canine
impaction in the maxilla is more than twice than that in the
mandible.5 Of all patients who have impacted maxillary
canines, eight percent have bilateral impactions.6
Approximately one third of impacted maxillary canines are
located labially and two-thirds are located palatally.7 In Asian
subjects, however, the impacted canines were usually midIndian Journal of Comprehensive Dental Care

Corresponding Author :
Kawar Randhawa.
MDS (Department of Oral Medicine, Diagnosis and Radiology)
Address: Sri Guru Ram Das Institute of Dental Sciences and
Research, Amritsar.
(M) 09872527749.
e-mail: kawarr7@gmail.com

alveolus or labial, and the prevalence ratio of European:

Asian for a palatal position has been reported to be be 5:1. 1, 8
Peck et al. have stated that the etiology of palatally impacted
canines is genetic in origin. The etiology of labially impacted
canines is due to an inadequate arch space.9 Impacted
canines vary greatly in the inclination and location and can
lead to resorption of neighbouring incisors, as well as cystic
degeneration. The orthodontic-surgical management of
impacted canines requires an accurate diagnosis and
localization of the impacted canine.1

172

Radiographs are indicated when canine bulges are not

present; right and left canine development and eruption is
asymmetrical; occlusal development is advanced and the
lateral incisor is delayed in eruption, mal-positioned, or has a
pronounced labial or palatal inclination in relation to the
adjacent central incisor. Accurate radiographs are critical for
determining the position of impacted canines and their
relation to adjacent teeth, assessing the health of the
neighbouring roots and determining the prognosis and best
mode of treatment. 10
Historically, several radiographic techniques have been
recommended, including periapical, occlusal, panoramic and
cephalometric radiographs, or a combination of these
approaches.3 When using these techniques, however, the
appearance of the longitudinal axis and the relationship with
the neighbouring bony and dental structures are often
inaccurate because these complex structures overlap in the
maxillofacial region. In such cases, therefore, several authors
have used computed tomography (CT)particularly spiral
CTfor localization of the impactions.1
Ericson and Kurol 11 found that periapical radiographs
allowed accurate location of the teeth in 92% of the cases
they evaluated. Although periapical films are diagnostic for
transverse position, occlusal radiographs are more accurate
for determining the positions of the canines relative to the
midline. Lateral cephalometric radiographs are also helpful in
assessing the anteriorposterior position of the displaced
tooth, as well as its inclination and vertical location in the
alveolus.10 It would be advantageous to use panoramic
radiographs in localizing impacted maxillary canines as it is
the most commonly recommended screening radiograph,
delivers relatively less radiation, easy to perform, costeffective and readily available.12 A panoramic radiograph
taken in conjunction with 2 periapical views obtained using
Clark's Rule (Buccal Object Rule) or a 60o maxillary occlusal
film allows the impacted teeth to be located either palatally
or buccally relative to adjacent teeth.10
AIMS AND OBJECTIVES
This study was designed to evaluate the reliability of a single
panoramic radiograph in localization of impacted permanent
maxillary canine by applying the criteria suggested by
Katsnelson et al. and by comparing the results with those
predicted by two periapical views using Clark's rule.
MATERIALS AND METHODS
The study subjects with impacted maxillary canine were
selected from outpatients visiting Department of Oral
Medicine and Radiology, Sri Guru Ram Das Institute Of Dental
Sciences & Research, Amritsar . The subjects ranged in age
from 12.3 to 34.6 years (mean 16.9 5.8 years). Exclusion
criteria included presence of craniofacial anomalies,

Indian Journal of Comprehensive Dental Care

incomplete root formation and existing orthodontic

appliance. For each subject, panoramic radiograph (using
digital panoramic Kodak 8000C machine) and two periapical
views with different horizontal angulation were taken.
Measurements were done on panoramic radiograph
according to the method suggested by Katsnelson et al. 2The
anatomic measure was the angulation of the canine to the
occlusal plane according to the panoramic radiograph. A
horizontal line was drawn from the mesiobuccal cusp tip of
the right and left maxillary first molars, and along the long
axis of the impacted canines. The inclination of the canine as
measured lateral to the midline was recorded in degrees. For
unilateral impactions, one angle was recorded and for
bilateral impactions, the angulations of both teeth were
recorded. The primary outcome variable was the location of
the impacted canine, which would be closer to the buccal
cortex (buccally impacted) or palatal cortex (palatally
impacted). (Fig. 1)

Figure 1: Measurement of angle on panoramic radiograph

Location of each impacted canine was also predicted on the
basis of two intraoral periapical views using principle of
parallax first introduced by Clark (1909). It involves two
radiographs taken at different horizontal angles with the
same vertical angulation. Due to parallax, the more distant
object appears to travel in the same direction as the tube
shift and the object closer to the tube appears to move in the
opposite direction [same lingual opposite buccal (SLOB)]. 13
The result obtained using both the techniques were then
compared using Cohen's Kappa statistics.
RESULTS
Out of 32 patients, 20 (62.5%) were females and 12 (37.5%)
were males. 8 patients had bilaterally impacted maxillary
canines. Of the 40 canines, 16 (40%) were on the right and 24
(60%) were on the left. Based on Clark's rule, out of 40 teeth,
16 (40%) were buccally located and 24 (60%) were found to
be palatally placed. The mean angulation of the canines in
the buccal group as measured on the panoramic radiograph
was 64.1o (range 40 o to 95 o) and in the palatal group was 50.2 o
(range 14.5 o to 84 o).
173

TABLES
Table 1- Distribution of angulation associated with
buccally impacted teeth versus palatally impacted teeth
Angulation frequency

Location of impaction
Buccal (n=16)

Palatal (n= 24)

11-20o

1(4.2%)

21-30 o

1(4.2%)

31-40 o

1(6.3 %)

3 (12.5%)

1(6.3 %)

12 (50%)

3 (18.8 %)

1(4.2%)

41-50

51-60 o
61-70

7(43.8%)

3(12.5 %)

71-80 o

3(18.8 %)

1(4.2%)

81-90 o

2 (8.3 %)

1(6.3 %)

5 (31.2%)

18 (75%)

11(68.8%)

6 (25%)

91-100
< 60

> 60 o

DISCUSSION
Disturbances in the eruption of permanent maxillary canines
are common because they develop deep within the maxilla
and have the longest path to travel compared with any other
tooth in the oral cavity. Canines play a vital role in facial
appearance, dental esthetics, arch development and
functional occlusion.4

Table 2- Accuracy of impacted canine

position predicted by panoramic radiograph
True

False

Positive

Positive (%)

Sensitivity Specificity Positive

(%)

Predictive

Accuracy
(%)

Value (%)
Buccal 11

64.71

78.26

68.75

Palatal 18

78.26

64.71

75.00

72.50

Table 3- Kappa value for canine position

predicted by panoramic radiograph
Symmetric Measures
N of Valid Cases=40

Measure of Agreement using

Asymp. Std. Approx.

Approx.

Value

Errora

Tb

Sig.

.433

.144

2.742

.006

Kappa statistics

a. Not assuming the null hypothesis.

b. Using the asymptotic standard error assuming
the null hypothesis.
Kappa key: Poor < 0.20; Fair, 0.20 to 0.40; Moderate,
0.40 to 0.60;Good , 0.60 to 0.80 ;perfect , 0.80 to 1.00

Table 1 shows the comparison between the angulations of

buccally and palatally impacted maxillary canines. Most
frequent angulation in the buccal group was 61-70o (43.8%)
whereas for palatally impacted teeth it was 41-50o (50%). Out
of the 16 teeth with buccally predicted positions, 11 (68.8%)
had angulation greater than 60o and 5 (31.2%) had angulation
less than 60o. Of the 24 palatally placed canines, angulation
measured for 18 (75%) teeth was less than 60o and for 6 (25%)
teeth was more than 60o.
The accuracy of impacted canine position as predicted by
panoramic radiograph (Table 2) is 72.5%. Sensitivity for the
buccally located canine is 64.71% and for palatal impaction is
78.26%. The positive predictive value for buccally and

Indian Journal of Comprehensive Dental Care

palatally placed canine is 68.75% and 75% respectively. Table

3 suggests that there is moderate agreement between the
techniques used in the study as suggested by Kappa value of
0.43. However the positions predicted by single panoramic
radiograph are statistically significant (p< 0.05)

Impacted permanent maxillary canines are most commonly

seen on the palatal side.1,4,10 In our study also palatal
impactions were more common (60%).In our study, similar to
other studies,1,4 63% of the individuals with impacted canines
were female.
Early localization of the impacted maxillary canine is
important as interceptive treatment, such as extraction of
the deciduous predecessor can allow spontaneous
correction in many cases. Several radiographic techniques
for determining the position of the unerupted maxillary
canines have been advocated in the past either in single or in
combinations, with every effort taken towards minimizing
the radiation dose and cost while maximizing the
information.12
In 1909, Clark 13 introduced the horizontal tube shift
technique using two periapical radiographs and later on in
1952. Richards14 introduced the concept of vertical tube shift.
Clark's rule enables the practitioner to determine the
location of impacted teeth. With this periapical film
technique, the clinician can evaluate the labiopalatal
position of the canine with sufficient accuracy in 92% of
patients.15
The idea of utilizing single panoramic radiograph in
localization was introduced by Wolf JE and Matilla K in 1979.16
Panoramic radiograph, usually taken as an initial radiograph
contains information about all the teeth in both arches as
well as about the jaws and surrounding structures.14Of late
computerized tomography (CT) and cone-beam computed
tomography (CBCT) have been proposed as an important
alternative. A recent CBCT study claims accurate examination
of the impacted canine is possible in both vertical and
horizontal planes along with its effect on adjacent structures.
Despite the more detailed information yielded by these
techniques, the comparable higher radiation dose and cost
outweigh their relative advantages.12
A study by Southall and Gravely on the radiograph
prescribing habits of dentists showed that 78% used more
than two and 23% used four or more radiographs to locate

174

the position of impacted canine. They further suggested that

clinicians should be encouraged to evaluate the radiographic
methods currently in use in terms of dose levels to which the
patients are exposed. If it can be shown that a single
radiographic technique provides the same information as
other techniques that require a higher radiation exposure,
the justification for the use of those with higher exposure
must be questioned. The panoramic radiograph is widely
used in general practice and is the first choice radiograph for
orthodontic patients. Use of the maximum amount of
information that can be obtained from such a radiograph
would help reduce unnecessary radiation exposure to
patients.17
Jacobs advocated that the horizontal tube shift between 2
occlusal films is more sensitive method of localising canines
than the vertical tube shift, which uses panoramic and
occlusal films.14 Wolf and Matilla proposed a rule that if
canine is superimposed on the roots of central incisor, it is
located palatally.16 However, Jacob reported a case that was
exception to this rule.14
Chaushu et al used vertical restriction parameter and
magnification index on a single panoramic radiograph for
determining the bucco-palatal position of the impacted
permanent maxillary canines.18 Sudhakar et al in their study
based on the criteria suggested by Chaushu et al noted that
although bucco-palatal position of the impacted permanent
maxillary canines can be predicted when they lie in the
middle and coronal zones, it is recommended to explore their
presence with other conventional or advanced imaging
modalities when they lie in the apical zone. 12
The study by Mason et al compared 2 techniques for the
localization of impacted maxillary canines: vertical parallax
(from a panoramic and a maxillary anterior radiograph) and
magnification (from a single panoramic radiograph). They
found that localization with vertical parallax was more
successful (76%) than localization with magnification (66%).
These differences were not statistically significant. Also,
palatally impacted canines could be correctly detected using
either technique in 90% of the cases, but buccal localization
could be detected with much less precision (parallax method
46% and magnification method 11%).The magnification
method also has limitations when the canine is rotated, in
contact with the incisor root, or the incisor root has not
tipped. 2,3
Overall, no method to depict the location of impacted
maxillary canine has been adequate till date , except for using
CT, which has its disadvantages owing to large amount of
radiation to the patient as well as financial burden. The
results of the present study suggest that position of the
impacted maxillary canine can be reliably predicted from a

Indian Journal of Comprehensive Dental Care

single panoramic radiograph (accuracy 72.5%).

Our study showed that teeth with angulation greater than
60o were more likely to be buccally impacted. One possible
explanation for why the angle correlates with location of the
canine is that if the tooth is in palatal position, it is positioned
horizontally in the sagittal plane at the palate and cannot be
positioned vertically because the palatal bone is thin in
sagittal dimension. This makes the angulation for palatally
located teeth likely to be less than 60o. 2
CONCLUSION
Canine impaction is a common occurrence. With early
detection, timely interception, and well-managed surgical
and orthodontic treatment, impacted maxillary canines can
be erupted and guided to an appropriate location in the
dental arch. The objective in localization is selection of a
suitable technique which has minimal radiation dose, cost
and maximum details. Panoramic radiograph, being a
screening radiograph, can satisfy the above needs and can
adequately predict the location of impacted maxillary
canines.
REFERENCES
1.

Liu DG, Zang WL, Zhang ZY, Wu YT, Ma XC. Localization of

impacted maxillary canines and observation of adjacent
incisor resorption with cone-beam computed
tomography. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008;105 :91-8.

2.

Katsnelson A, Flick WG,Susarla S, Tartakovsky JV, Miloro

M. Use of panoramic X-ray to determine position of
impacted maxillary canines. J Oral Maxillofac Surg 2010;
68: 996-1000.

3.

Mason C, Papadakou P, Roberts GJ. The radiographic

localization of impacted canines: a comparison of
methods. Eur J Orthod 2001;23 : 25-34.

4.

Bedoya MM and Park JH. A Review of the Diagnosis and

Management of Impacted Maxillary Canines. J Am Dent
Assoc 2009;140 :1485-1493.

5.

Yavuz MS, Aras MH, Buyukkurt MC, Tozoglu S. Impacted

mandibular canines. J Contemp Dent Pract 2007;8
(7):78-85.

6.

Bishara SE. Impacted maxillary canines: a review. Am J

Orthod Dentofacial Orthop 1992; 101 (2):159-171.

7.

Ericson S, Kurol J. Early treatment of palatally erupting

maxillary canines by extraction of the primary canines.
Eur J Orthod 1988;10(4):283-295.

8.

Maverna R, Gracco A. Different diagnostic tools for the

localization of impacted maxillary canines: clinical
considerations. Prog Orthod 2007;8(1):28-44.

9.

Peck S, Peck L, Kataja M. The palatally displaced canine

175

as a dental anomaly of genetic origin. Angle Orthod

1994;64:249-56.
10. Richardson G, Russell KA. A Review of impacted
permanent maxillary cuspids - Diagnosis and
Prevention.J Can Dent Assoc 2000; 66:497-501.

and Huang JC. Comparative analysis of traditional

radiographs and cone beam computed tomography
volumetric images in the diagnosis and treatment
planning of maxillary impacted canines. Am J Orthod
Dentofac Orthop 2010;137: 590-7.

Ericson S, Kurol J. Radiographic examination of

ectopically erupting maxillary canines. Am J Orthod
Dentofacial Orthop 1987; 91:483-92.

16. Wolf JE, Matilla K. Localization of Impacted canines by

panoramic radiography. Dentomaxillofac Radiol 1979;8
:85-91.

12. Sudhakar S, Patil K, Mahima VG. Localization of

impacted permanent maxillary canine using single
panoramic radiograph. Indian J Dent Res, 2009;20(3):
340-345.

17. Southall PJ, Gravely JF. Radiographic localization of

unerupted teeth in the anterior part of the maxilla: A
survey of methods currently employed. Br J Orthod
1987;14: 235-42.

13. Clark CA. A method of ascertaining the relative position

of the unerupted teeth by means of film radiography.
Odont Sec R Soc Med Trans 1909;3:87.

18. Chaushu S, Chaushu G, Becker A. The use of panoramic

radiographs to localize displaced maxillary canines. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:
511-6.

11.

14. Jacobs SG. Radiographic localization of unerupted

teeth: further findings about vertical tube shift method
and other localization techniques. Am J Orthod
Dentofac Orthop 2000;118: 439-47.
15. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ

Indian Journal of Comprehensive Dental Care

176