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Dental Science - Review Article

Impacted canines: Etiology, diagnosis, and


orthodontic management
Ranjit Manne, ChandraSekhar Gandikota, Shubhaker Rao Juvvadi, Haranath
Reddy Medapati Rama, Sampath Anche1

Departments of ABSTRACT
Orthodontics and
Impaction of maxillary and mandibular canines is a frequently encountered clinical problem, the treatment of
Dentofacial Orthopedics,
1
Oral and Maxillofacial
which usually requires an interdisciplinary approach. Surgical exposure of the impacted tooth and the complex
Surgery, Panineeya Dental orthodontic mechanisms that are applied to align the tooth into the arch may lead to varying amounts of damage
College, Hyderabad, India to the supporting structures of the tooth, not to mention the long treatment duration and the financial burden
to the patient. Hence, it seems worthwhile to focus on the means of early diagnosis and interception of this
Address for correspondence: clinical situation. In the present article, an overview of the incidence and sequelae, as well as the surgical,
Shubhaker Rao Juvvadi periodontal, and orthodontic considerations in the management of impacted canines is presented.
E-mail: shubhaker@gmail.
com
Received : 01-12-11
Review completed : 02-01-12
Accepted : 26-01-12 KEY WORDS: Diagnosis, etiology, impacted canines, orthodontic techniques, prevention, surgical techniques

T he orthodontic treatment of impacted maxillary canine


remains a challenge to todays clinicians. The treatment
of this clinical entity usually involves surgical exposure of the
can be allowed to erupt and be guided to an appropriate location
in the dental arch. However, it is only with interdisciplinary
care of general dentists and specialists that impacted maxillary
impacted tooth, followed by orthodontic traction to guide and canines can be treated successfully.
align it into the dental arch. Bone loss, root resorption, and
gingival recession around the treated teeth are some of the most Prevalence and Etiology
common complications.
Maxillary canines are the most commonly impacted teeth, second
Early diagnosis and intervention could save the time, expense, only to third molars.[2] Maxillary canine impaction occurs in
and more complex treatment in the permanent dentition. approximately 2% of the population and is twice as common in
Tooth impaction can be defined as the infraosseous position females as it is in males. The incidence of canine impaction in the
of the tooth after the expected time of eruption, whereas the
maxilla is more than twice that in the mandible. Of all patients who
anomalous infraosseous position of the canine before the
have impacted maxillary canines, 8% have bilateral impactions.[3]
expected time of eruption can be defined as a displacement.
Approximately one-third of impacted maxillary canines are located
Most of the time, palatal displacement of the maxillary canine
labially and two-thirds are located palatally.[4,5] Canine impaction
results in impaction.[1,2]
can be caused by various factors. The exact etiology of palatally
displaced maxillary canines is unknown. The results of Jacobys[6]
With early detection, timely interception and well-managed
surgical and orthodontic treatment, impacted maxillary canines study showed that 85% of palatally impacted canines had sufficient
space for eruption, whereas only 17% of labially impacted canines
Access this article online had sufficient space. Therefore, arch length discrepancy is thought
Quick Response Code: to be a primary etiologic factor for labially impacted canines.[5]
Website: Several etiologic factors for canine impactions have been proposed:
www.jpbsonline.org localized, systemic, or genetic [Box 1].[1]

DOI: Two major theories associated with palatally displaced maxillary


10.4103/0975-7406.100216 canines are the guidance theory and genetic theory.[7] The guidance
theory proposes that the canine erupts along the root of the lateral

How to cite this article: Manne R, Gandikota C, Juvvadi SR, Medapati Rama H, Anche S. Impacted canines: Etiology, diagnosis, and orthodontic management.
J Pharm Bioall Sci 2012;4:234-8.

S234 Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012 Supplement 2 - Part 2
Manne, etal.: Orthodontic management of impacted canines

Box 1: Etiologic factors associated with impacted canines Clinical Evaluation


Localized
Tooth sizearch length discrepancies It has been suggested that the following clinical signs might be
Failure of the primary canine root to resorb indicative of canine impaction:[3]
Prolonged retention or early loss of the primary canine
1. Delayed eruption of the permanent canine or prolonged
Ankylosis of the permanent canine
Cyst or neoplasm retention of the deciduous canine beyond 1415 years of age,
Dilaceration of the root 2. Absence of a normal labial canine bulge,
Absence of the maxillary lateral incisor 3. Presence of a palatal bulge, and
Variation in root size of the lateral incisor (peg-shaped lateral 4. Delayed eruption, distal tipping, or migration (splaying) of
incisor)
Variation in timing of lateral incisor root formation
the lateral incisor.
Iatrogenic factors
Idiopathic factors According to Ericson and Kurol,[12] the absence of the canine
Systemic bulge at earlier ages should not be considered as indicative
Endocrine deficiencies of canine impaction. In their evaluation of 505 schoolchildren
Febrile diseases
Irradiation
between 10 and 12 years of age, they found that 29% of the
Genetic children had nonpalpable canines at 10 years, but only 5% had it
Heredity at 11 years, whereas at later ages only 3% had nonpalpable canines.
Malposed tooth germ Therefore, for an accurate diagnosis, the clinical examination
Presence of an alveolar cleft should be supplemented with a radiographic evaluation.

incisor, which serves as a guide, and if the root of the lateral incisor Radiographic Evaluation
is absent or malformed, the canine will not erupt.[8]
Although various radiographic exposures including occlusal
The genetic theory points to genetic factors as a primary origin of films, panoramic views, and lateral cephalograms can help in
palatally displaced maxillary canines and includes other possibly evaluating the position of the canines, in most cases, periapical
associated dental anomalies, such as missing or small lateral films are uniquely reliable for that purpose.[3,13]
incisors.[9] Baccetti[10] reported that palatally impacted maxillary
canines are genetically reciprocally associated with anomalies Periapical films
such as enamel hypoplasia, infraocclusion of primary molars,
aplasia of second premolars, and small maxillary lateral incisors. A single periapical film provides the clinician with a two-
dimensional representation of the dentition. In other words,
Sequelae of Canine Impaction it would relate the canine to the neighboring teeth both
mesiodistally and superoinferiorly. To evaluate the position of
Shafer et al.[11] suggested the following sequelae for canine the canine buccolingually, a second periapical film should be
impaction: obtained by one of the following methods.
1. Labial or lingual malpositioning of the impacted tooth,
2. Migration of the neighboring teeth and loss of arch length, Tube-shift technique or Clarks rule or (SLOB) rule
3. Internal resorption,
4. Dentigerous cyst formation, Two periapical films are taken of the same area, with the
5. External root resorption of the impacted tooth, as well as
horizontal angulation of the cone changed when the second film
the neighboring teeth,
is taken. If the object in question moves in the same direction
6. Infection particularly with partial eruption, and
as the cone, it is lingually positioned. If the object moves in the
7. Referred pain and combinations of the above sequelae.
opposite direction, it is situated closer to the source of radiation
It is estimated that in 0.71% of children in the 1013 year and is therefore buccally located.
age group, permanent incisors have resorbed because of the
ectopic eruption of maxillary canines.[12] On the other hand, Buccal-object rule
the presence of the impacted canine may cause no untoward
effects during the lifetime of the person. If the vertical angulation of the cone is changed by approximately
20 in two successive periapical films, the buccal object will move
These potential complications, as well as others that will be in the direction opposite to the source of radiation. On the other
detailed later, emphasize the need for close observation of the hand, the lingual object will move in the same direction as the
development and eruption of these teeth during routine source of radiation. The basic principle of this technique deals
periodic dental examination of the growing child. with the foreshortening and elongation of the images of the films.

Diagnosis of Canine Impaction Occlusal films

The diagnosis of canine impaction is based on both clinical and Also help to determine the buccolingual position of the impacted
radiographic examinations. canine in conjunction with the periapical films, provided that

Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012 Supplement 2 - Part 2 S235
Manne, etal.: Orthodontic management of impacted canines

the image of the impacted canine is not superimposed on the


other teeth.

Extraoral films

Frontal and lateral cephalograms

These can sometimes aid in the determination of the position of


the impacted canine, particularly its relationship to other facial
structures (e.g., the maxillary sinus and the floor of the nose).

Panoramic films

These are also used to localize impacted teeth in all three planes
of space, as much the same as with two periapical films in the
tube-shift method, with the understanding that the source of
Figure 1: Schematic illustration showing the normalization rates of
radiation comes from behind the patient; thus, the movements the maxillary canine after extraction of the primary canine when the
are reversed for position. permanent maxillary canine is located mesially and distally to the
midline of the lateral incisor
CT/CBCT
for any pathologic changes. It should be remembered that
Clinicians can localize canines by using advanced three- the long-term prognosis for retaining the deciduous canine
dimensional imaging techniques. Cone beam computed is poor, regardless of its present root length and the esthetic
tomography (CBCT) can identify and locate the position of acceptability of its crown. This is because, in most cases,
impacted canines accurately. By using this imaging technique, the root will eventually resorb and the deciduous canine will
dentists also can assess any damage to the roots of adjacent have to be extracted.
teeth and the amount of bone surrounding each tooth. However, 2. Autotransplantation of the canine.
increased cost, time, radiation exposure, and medicolegal issues 3. Extraction of the impacted canine and movement of a first
associated with using CBCT limit its routine use. premolar in its position.
4. Extraction of the canine and posterior segmental osteotomy to
The proper localization of the impacted tooth plays a crucial move the buccal segment mesially to close the residual space.
role in determining the feasibility of as well as the proper 5. Prosthetic replacement of the canine.
access for the surgical approach and the proper direction for 6. Surgical exposure of the canine and orthodontic treatment
the application of orthodontic forces. to bring the tooth into the line of occlusion. This is obviously
the most desirable approach.
Interceptive Treatment
When to Extract an Impacted Canine
When the clinician detects early signs of ectopic eruption of the
canines, an attempt should be made to prevent their impaction It should be emphasized that extraction of the labially
and its potential sequelae. Selective extraction of the deciduous erupting and crowded canine, unsightly as this tooth may
canines as early as 8 or 9 years of age has been suggested by look, is contraindicated. Such an extraction might temporarily
Williams as an interceptive approach to canine impaction in improve the esthetics, but may complicate and compromise the
Class I uncrowded cases. Ericson and Kurol[12] suggested that orthodontic treatment results, including the ability to provide
removal of the deciduous canine before the age of 11 years will the patient with a functional occlusion. The extraction of the
normalize the position of the ectopically erupting permanent canine, although seldom considered, might be a workable option
canines in 91% of the cases if the canine crown is distal to the in the following situations:[3]
midline of the lateral incisor. On the other hand, the success 1. If it is ankylosed and cannot be transplanted,
rate is only 64% if the canine crown is mesial to the midline of 2. If it is undergoing external or internal root resorption,
the lateral incisor [Figure 1].[12] 3. If its root is severely dilacerated,
4. If the impaction is severe (e.g., the canine is lodged between
Treatment alternatives the roots of the central and lateral incisors and orthodontic
movement will jeopardize these teeth),
Each patient with an impacted canine must undergo a 5. If the occlusion is acceptable, with the first premolar in the
comprehensive evaluation of the malocclusion. The clinician position of the canine and with an otherwise functional
should then consider the various treatment options available occlusion with well-aligned teeth,
for the patient, including the following:[3] 6. If there are pathologic changes (e.g., cystic formation,
1. No treatment if the patient does not desire it. In such a case, infection), and
the clinician should periodically evaluate the impacted tooth 7. If the patient does not desire orthodontic treatment.

S236 Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012 Supplement 2 - Part 2
Manne, etal.: Orthodontic management of impacted canines

Management of Impacted Canines

The most desirable approach for managing impacted maxillary


canines is early diagnosis and interception of potential
impaction. However, in the absence of prevention, clinicians
should consider orthodontic treatment followed by surgical
exposure of the canine to bring it into occlusion. In such a
case, open communication between the orthodontist and oral
surgeon is essential, as it will allow for the appropriate surgical
and orthodontic techniques to be used. a b c
Figure 2: Recommended surgical techniques relative to the
The most common methods used to bring palatally impacted mucogingival junction (MGJ) when the canine cusp is (a) coronal to
the MGJ: gingivectomy; (b) apical to the MGJ: creating an apically
canines into occlusion are surgically exposing the teeth and
positioned flap; and (c) significantly apical to the MGJ: using a closed
allowing them to erupt naturally during early or late mixed eruption technique
dentition and surgically exposing the teeth and placing a bonded
attachment to and using orthodontic forces to move the tooth.[14]
Table 1: A summary of orthodontic techniques used to
Kokich[15] reported three methods for uncovering a labially
manage impacted canines
impacted maxillary canine: gingivectomy, creating an apically
Study Orthodontic technique
positioned flap, and using closed eruption techniques [Figure 2].
Harry Jacobay[16] (1979) Ballista spring
Criscini etal.[17] (1994) Tunnel traction
Orthodontists have recommended that other clinicians first Ali Darendeliler[18] (1994) Magnets[19]
create adequate space in the dental arch to accommodate the Becker etal.[8] (1995) Stainless steel archwire auxillary
impacted canine and then surgically expose the tooth to give Lindauer and Isaacson[20] (1995) Cantilever spring
them access so that they can apply mechanical force to erupt Lindauer and Isaacson[20] (1995) TMA box loop
the tooth. Although various methods work, an efficient way to Samuels[21] (1997) Two archwire technique
Loring L. Ross[22] (1999) Nickel titanium closed-coil spring
make impacted canines erupt is to use closed-coil springs with Pramod K. Sinha[23] (1999) Mandibular achorage
eyelets, as long as no obstacles impede the path of the canine. Varun Kalra[24] (2000) The K-9 spring
Christine Hauser[25] (2000) Australian helical archwire
If the canine is in close proximity to the incisor roots and a Jay Bowman[26] (2002) The monkey hook
buccally directed force is applied, it will contact the roots Dillingham (2002) Park and Temporary anchorage devices (TADS)
collegues[27] (2004)
and may cause damage. In addition, the canine position
may not improve due to the root obstacle. Consequently,
various techniques have been proposed that involve moving patients are evaluated and treated properly, clinicians can reduce
the impacted tooth in an occlusal and posterior direction the frequency of ectopic eruption and subsequent impaction
first and then moving it buccally into the desired position. of the maxillary canine.
When using a bonded attachment and orthodontic forces to
bring the impacted canines into occlusion, it is important to The simplest interceptive procedure that can be used to prevent
remember that first premolars should not be extracted until a impaction of permanent canines is the timely extraction of the
successful attempt is made to move the canines. If the attempt primary canines. This procedure usually allows the permanent
is unsuccessful, the permanent canines should be extracted. canines to become upright and erupt properly into the dental
arch, provided sufficient space is available to accommodate them.
A summary of orthodontic techniques used to manage impacted
canines is given in Table 1. Various surgical and orthodontic techniques may be used to recover
impacted maxillary canines.[28] The proper management of these
In such cases, the orthodontist has to decide if the premolar teeth, however, requires that the appropriate surgical technique
should be moved into the canine position. Orthodontists should be used and that the clinician be able to apply measured forces in
consider treatment alternatives, such as autotransplantation or a favorable direction. This allows for complete control in efficient
restoration, in collaboration with other specialists, including correction the impaction and for avoidance of damage to adjacent
oral surgeons, periodontists, and prosthodontists. The patient teeth. Careful selection of surgical and orthodontic techniques is
should be informed about all of the potential complications essential for the successful alignment of impacted canines.
before surgical and orthodontic interventions take place.
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