The European Journal of Orthodontics Advance Access published September 22, 2014

European Journal of Orthodontics, 2014, 110

doi:10.1093/ejo/cju040

Randomized controlled trial

Extraction of the deciduous canine as an

interceptive treatment in children with palatal
displaced caninespart I: shall we extract the
deciduous canine or not?
Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

JuliaNaoumova, JriKurol and HeidrunKjellberg

Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy, University of Gothenburg, Gteborg, Sweden
Correspondence to: Julia Naoumova, Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy,
University of Gothenburg, PO Box 450, SE-405 30 Gteborg, Sweden. E-mail: julia.naoumova@vgregion.se

Summary
Objectives: To analyse whether extraction of the deciduous canines facilitates eruption of the palatal
displaced canines (PDCs), and to analyse root resorption in adjacent teeth caused by the PDCs.
Materials and methods: Eligibility criteria for participants were as follows: children at age 10-13 years
with either maxillary unilateral or bilateral PDC, persisting deciduous canine and no previous experience
of orthodontic treatment. Sixty-seven patients (40 girls and 27 boys; age: mean standard deviation:
11.41.0) with unilateral (45) or bilateral (22) PDCs were consecutively recruited and randomly allocated
using permuted block randomization method to extraction or non-extraction. No patients dropped out
after the randomization or during the study. Patients underwent a clinical examination and cone beam
computed tomography at baseline (T0), after 6 (T1) and 12months (T2). The total observation time
was 24months. Outcome measures were eruption, positional changes, length of time until eruption,
and root resorption of adjacent teeth. The baseline images were measured blinded while the 6- and
12-month control images were not, since it was not possible to blind the extracted canine.
Results: Significantly more spontaneous eruptions of the PDCs were seen in the extraction group
(EG) than in the control group (CG), with rates of 69 and 39 per cent, respectively, with a mean
eruption time of 15.65.6months in the EG and 18.85.8months in the CG. Significant differences
in changes between the groups, in favour of the EG, were found for all variables except for the
sagittal angle. In the EG, the changes in the distances of the canine cusp-tip were larger during
the first 6months, while the change of apex was larger between 6 and 12months. There were no
significant differences in resorption of adjacent teeth between the groups.
Limitations: Imputation values were used for the PDCs who had erupted atT2, since no x-rays were taken
for ethical reasons, which might have given uncertainty in the positional changes between T1 and T2.
Conclusions: Extraction of the deciduous canine is an effective treatment in patients with PDCs.
Significantly more positional changes and shorter mean eruption time were seen in the EG.
Resorptions of lateral incisors were seen in both groups, but none exceeded grade 2 (resorption
up to half of the dentine thickness to the pulp).
Registration: This trial was registered in FoU i Sverige (http://www.fou.nu/is/sverige), registration
number: 40921.
Protocol: The protocol was not published before trial commencement.
Funding: The Local Research and Development Board for Gothenburg and Sdra Bohusln and
from the Health & Medical Care Committee of the Regional Executive Board, Vstra Gtaland Region.

The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
For permissions, please email: journals.permissions@oup.com

European Journal of Orthodontics, 2014

Introduction

Materials and methods

Prevention of palatally displaced canines (PDCs) from becoming

impacted is of significant importance because an impaction lengthens the orthodontic treatment, complicates orthodontic mechanics (1, 2), increases the treatment costs (3), and increases the risk of
root resorption of adjacent teeth with a potential result of tooth loss
(46). Early interceptive treatment is therefore desirable. The prevalence of PDC varies between 0.9 and 2.8 per cent and depends on
the patients ethnic origin, gender, and the diagnostic methods used.
Canine impaction occurs twice as frequently in females than in males
and 85 per cent of the impacted canines are located palatally (79).
The aetiology of PDC is still unknown, but two theories are widely
mentioned in the literature, i.e. the guidance theory (10, 11) and the
genetic theory 1215.
One of the most common methods used to diagnose PDC is
comprised of two periapical radiographs taken from different views,
known as Clarks rule (1618). Cone beam computed tomography
(CBCT) has recently been presented for imaging the craniofacial
field, and several studies have reported the advantage of CBCT over
conventional radiographs for localizing canines and identifying root
resorptions on adjacent teeth (1921).
Interceptive extraction of the deciduous canine was recommended in 1936 to facilitate the eruption of the impacted maxillary
canines and prevent the risk of resorption (22). This treatment was
later evaluated in a prospective uncontrolled study by Ericson and
Kurol (23), who concluded that extraction in patients with PDCs is
an effective intervention and the success rate depends on the mesiodistal location of the crown and the patients age at the diagnosis.
The authors presented a treatment protocol that is widely used by
many dentists all over theworld.
However, in two newly published systematic reviews assessing
whether interceptive treatment in the mixed dentition prevents impaction of PDC, it was concluded that the scientific evidence still is too
weak to fully evaluate the effect that interceptive treatment might have
on PDC (24, 25). Several randomized controlled trial (RCT) studies have
been published after the two systematic reviews, comparing extraction
of the deciduous canine to other treatment methods such as expansion
(26), space maintainer (27), or double extraction, i.e. extraction of the
deciduous canine concomitant to extraction of the first deciduous molar
(28). All three treatment methods resulted in more successful canine
eruption than extraction of the deciduous canine alone. A new prospective study comparing extraction of the deciduous canines with no
extraction on patients with bilateral PDC was very recently published
and concluded that extraction is an effective measure (29). According
to the studies mentioned previously, the results show that extraction of
the deciduous canine is effective in patients with PDC, but no previous
study has assessed the three-dimensional (3D) depth of the impaction
and the outcome using the CBCT technique.
Therefore, the aims of this study wereto

Trial design

It was hypothesized that there are no significant differences between

the EG and the CG regarding 1) the success rate of spontaneous
eruption of the PDC, 2) change in eruption pattern, or 3) for the
number of root resorptions of adjacent teeth, after interceptive
extraction of the deciduous canine.

Extraction group (EG)

Control group (CG)
which took place at the clinic of orthodontics, University Clinics of
Odontology, Gothenburg, Sweden.
Patients with unilateral PDC were randomized either to have
extraction of the deciduous canine or non-extraction and patients
with bilateral PDC were randomized to have either the right or the
left deciduous canine extracted (Figure 1).

Registration
This trial was registered in FoU i Sverige (http://www.fou.nu/is/sverige),
registration number: 40921.

Ethical issue
The research ethics committee of the Sahlgrenska Academy,
Gothenburg, Sweden, approved the protocol of the study (Dnr 57808). Children and parents received verbal and written information,
and informed consent was provided by the child and their parent or
by an adult with parental responsibilities and rights in accordance
with the Declaration of Helsinki.

Screening ofPDC
The general practitioner identified participants for the trial, who were
consecutively recruited from 15 public dental clinics in Gothenburg,
Vstra Gtaland County Council, Sweden, between September 2008 and
January 2011. During their visit to the public dental clinic, the consulting
orthodontist then invited the potential patients to participate in the study.

Subjects, eligibility criteria and setting

Study setting and eligibility criteria
Patients interested in participating received an appointment letter in
which a website (http://www.odontologi.gu.se/horntand.html) was
enclosed that contained information about the study. Another website (http://www.odontologi.gu.se/horntand_tdl) was established for
the general practitioners and for the orthodontists, where they could
access information about thestudy.
The inclusion criteria were as follows:
Caucasians at age 1013 years with either maxillary unilateral
or bilateral PDC
Persisting deciduous canine
No previous experience of orthodontic treatment
The canine was considered palatally displaced when clinical palpation of a labial canine bulge was absent and when the canine crown
was diagnosed on intraoral radiographs as palatally positioned,
using Clarksrule (30).
Criteria for exclusion were as follows:
Crowding in the maxilla exceeding 2mm
Ongoing orthodontic treatment
Resorption of the adjacent teeth, grades 3 and 4 according to
Ericson and Kurol (31), either at the start or during the trial
caused by the displaced canine.
Craniofacial syndromes
Odontomas, cysts
Cleft lip and/or palate

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

1. Evaluate the effect of interceptive extraction of the deciduous

canine in children with PDC compared with a control group
(CG) using an RCT methodology with a CBCT technique.
2. Assess the radiographic changes in eruption between the extraction group (EG) and the CG in time, i.e. between 0 to 6 and 6 to
12months after extraction.
3. Analyse root resorption on adjacent teeth caused by the PDCs.

This randomized controlled clinical trial with an equal patient allocation to the two groups:

J. Naoumova etal.

Assessed for eligibility

N = 70
Declined to enter the
study N= 3. Age (mean
SD: 11.50.7)
Randomized patients N = 67
40 girls (mean age SD:
11.3 1.1), 27 boys (mean
age SD: 11.4 0.9)

Unilateral PDC

Baseline, T0

Clinical examination, CBCT

N = 67
(40 girls, 27 boys)

6 month control, T1

Clinical examination, CBTC

N = 67
(40 girls, 27 boys)

Allocated to extraction of
the deciduous canine
N = 23; 9 boys, 14 girls
Age (mean SD: 11.21.1)

Allocated to extraction of
the right deciduous canine
N = 22; 11 boys, 11 girls
Age (mean SD: 11.6 1.0)

Allocated to extraction of the

left deciduous canine
N = 22; 11 boys, 11 girls
Age (mean SD: 11.6 1.0

Non-extraction of the
deciduous canine i.e. control
group (CG)
N = 44 PDCs

Extraction of the deciduous

canine i.e. extraction group
(EG)
N = 45 PDCs

Non-extraction of the
deciduous canine i.e. control
group (CG)
N = 44 PDCs

Extraction of the deciduous

canine i.e. extraction group
(EG)
N = 45 PDCs

12 month control, T2

Analysed

Clinical examination, CBCT

N = 67
N = 52
(40 girls, 27 boys)

N = 89 PDCs

Individual treatment plan

N =71 PDCs

Impairment or no
change of the canine
position
Surgical exposure
and orthodontic
treatment
N = 41 PDCs

Improved position
of the canine
Clinical
examination. Xray if needed, total
observation period
24 months
N = 30 PDCs

N: number of patients, PDCs: palatally displaced canines; SD: standard deviation; CBCT: cone beam computer tomography
Figure1. Flowchart describing the protocol and the patients included in the study. No patients dropped out after the randomization or during the study.

The Ericson and Kurol (31) classification of root resorption is

1)no resorption, intact root surfaces, and the cementum layer may
be lost; 2) slight resorption, resorption up to half of the dentine
thickness to the pulp; 3)moderate resorption, resorption midway

to the pulp or more, the pulp lining being unbroken; and 4)severe
resorption, the pulp is exposed by the resorption. Resorption
grades 3 and 4 were excluded from the trial, while 1 and 2 were
included.

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

Allocated to non-extraction
N = 22; 7 boys, 15 girls
Age (mean SD: 11.31.1)

bilateral PDCs

European Journal of Orthodontics, 2014

4
A total of 70 patients were invited to take part in the study. Three
patients, all girls with bilateral PDCs, declined to participate at the
first visit when information was given about the study, i.e. before they
were randomized. Two out of the three patients declined due to fear
of extraction and one patient thought it was too far to travel to the
clinic of orthodontics, University Clinics of Odontology, Gothenburg,
Sweden. No patients dropped out after the randomization or during
the study. Thus, in total 67 patients were randomly allocated to the
extraction or the CG. Of these, 45 patients had unilateral PDC and
22 patients had bilateral PDCs (Figure1).

Randomization method
For randomization, the permuted block randomization method was
used and the allocations were concealed in sequentially numbered,
sealed opaque envelopes opened by a dental nurse after the written
consent was obtained.

All patients who decided to participate in the study, regardless of the

group to which they were randomized, underwent a radiographic
examination consisting of CBCT images at the Department of Oral
and Maxillofacial Radiology, Institute of Odontology, Sahlgrenska
Academy, Gothenburg, Sweden. The radiographic examination is
explained in detailed in a previously published study (32). Extraction
of the deciduous canines was carried out by one orthodontist (JN)
on the same day as the baseline radiographic examination (T0) in
order to get a precise timing of the start of the intervention.
After 6 months (T1), patients in the EG and the CG were clinically examined by the same orthodontist who carried out the baseline
examinations. If the permanent canine was not clinically visible, the

Blinding
One oral radiologist unaware of the group to which the patients
belonged carried out all the measurements on the CBCT images in
axial, sagittal, and frontal views. The baseline images were, therefore, measured blinded, while the 6 and 12 month control images
were not because it was not possible to blind the extracted canine.
The following outcome measures were assessed:
Primary outcome
Eruption of the permanent canine, i.e. successful outcome
(defined as canine emerged through the gingiva) during the total
observation time, i.e. 24months.

Figure2. Radiographic measurements of the cone beam computed tomography images assessed in coronal, sagittal, and axial plane.

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

Treatment protocol and process

patient underwent a new radiographic examination (CBCT images)

the same day. This procedure was repeated at the 12month control
(T2). Figure1 describes the protocol and the patients included in the
study. All patients were given a diary to document the date of the
eruption in those cases the canine started to erupt before the next
check-up. In patients with clinically visible canines, i.e. that emerged
through the gingiva, no further CBCTs weretaken.
An individual treatment plan was drawn up for patients with
unerupted PDCs after 12 months. The unerupted canines, in cases
that the canine had improved its position on the radiographic examination, were followed until they emerged through the gingiva with
continuing check-ups in the EG. In the CG, the deciduous canine was
extracted if mobility of the tooth was not present. When the canine
showed impairment or no change in its position at the 12month control, a combined surgical exposure and orthodontic treatment was
performed, regardless of the group to which the patient belonged.

J. Naoumova etal.
Secondary outcome
Positional changes of the permanent canine over time (T1T0
and T2T1) measured from the radiographs: mesioangular angle,
sagittal angle, vertical position, canine cusp tip-dental arch plane,
canine root apex-dental arch plane, canine cusp tip-midline
(Figure 2) and changes between T1T0 and T2T1 within and
between the EG and the CG.
Root resorption of adjacent teeth.

Imputation of measurementvalues
Missing data can introduce bias and affect the results because most
statistical packages automatically discard cases with missing values.
This can be avoided by applying imputation, a statistical process of
replacing missing data with probability values based on other available information. In this case, angular and linear measurements of
fully erupted maxillary canines were imputed.
As described previously, in patients in whom the permanent
canine had started to erupt and was clinically visible, no further radiographic examinations were done. Instead, imputation values were
used (applicable only at T2, 12months), which were calculated by
measuring the mean angular and linear measurements of 10 unilateral patients (8 girls, age: mean standard deviation [SD]: 11.20.9;
2 boys, 11.7 and 10.6years of age at baseline), whose contralateral
non-PDC was fully or partial erupted.

Sample size calculation

The sample size was based on the alpha significance level of 0.05 and
a beta of 0.10 to achieve a 90 per cent power to detect a difference of
5 degrees (SD 6.38) of the angle measured in the frontal and sagittal
views, between the extraction and the CG. The calculation indicated
that in total 60 patients with unilateral PDC were needed, i.e. 30
patients in each group. Inclusion of bilateral PDC reduced the number of patients needed. To compensate for possible dropouts during
the study, in total 70 patients were identified, 67 were enrolled.

Statistics
The data were statistically analysed using SAS, version 9.3 for
Windows (SAS Institute Inc., Cary, North Carolina, USA). Arithmetic
means and standard deviations were measured for numerical variables. Dependent and independent t-tests were used to compare
the baseline variables and changes in time between and within the
groups, respectively. The independent t-test was used to test whether
there were any significant differences in the linear and angular variables between successful versus non-successful outcome. Fishers
exact test was used to calculate differences in categorical data, such
as the success in the eruption rate between the extraction versus the

non-EG, gender, extraction site, and extraction versus non-extraction. To test whether the bilateral group would be considered independent observations or dependent paired observations, the main
outcome, i.e. eruption or non-eruption, was tested with Fishers
exact test and McNemars test. As no multiple comparisons have
been tested, adjustment or correction with statistical analysis was
not needed.

Harms
No harms were detected during the study.

Results
The extracted deciduous canines showed no root resorption or less
than one-third of the root length resorbed, and none were mobile.

Participant flow
Fifteen out of the 67 patients (3 bilateral PDC and 12 unilateral PDC
[3 from the CG and 9 from the EG]) did not have a radiographic
examination at the 12 month control because the canines had
emerged through the gingiva and were under eruption, i.e. clinically
visible between T1 and T2. Imputation values were used in thesecases
(Figure 1).

Baseline findings
There were no significant differences at T0, either for the mean age
between the unilateral and bilateral groups (Table1) or between the
angular and linear measurements in the EG and the CG (Table2).
Dividing the subject into age groups of 1011- and 1213-year-old
individuals showed that there were a larger number of patients in
the younger group. There were more females than males in total, but
no significant differences were seen in gender distribution between
the unilateral and bilateral groups or the extraction and non-EGs. In
addition, no differences were seen between the left and right extraction sites (Table1).
It was decided to analyse the whole material and not only the
unilateral group as two independent observations because there was
no difference in the correlation between extraction and successful
outcome between independent observations and dependent paired
observations in the bilateral group. Further, there were no significant
differences in the patients characteristics when the bilateral and unilateral PDC patients were put together in the EG and CG.
Table 1.Patient characteristics in the unilateral and bilateral
groups at baseline. PDC, palatal displaced canines; SD, standard
deviation

Patients (n)
Age (mean SD)
Age (y), n (%)
1011
1213
Female, n (%)
Male, n (%)
Extraction, n (%)
Right side, n (%)
Left side, n (%)
Non-extraction, n (%)

Unilateral PDC

Bilateral PDC

Total

45
11.20.9

22
11.61.0

67
11.41.0

30 (67)
15 (33)
29 (64)
16 (36)
23 (51)
7 (30)
16 (70)
22 (50)

13 (59)
9 (41)
11 (50)
11 (50)
22 (49)
13 (59)
9 (41)
22 (50)

43 (64)
24 (36)
40 (60)
27 (40)
45 (51)
20 (45)
25 (55)
44 (49)

n indicates number of patients and % indicates percentage of patients.

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

Positive values for the variables: canine cusp tip-dental arch plane
and canine root apex-dental arch plane indicate a palatal position of
the cusp-tip or apex and a negative value buccal position in relation
to the dental archplane.
The methodology of the radiographic measurements has been
described in detail in a previously published study, in which the intraand inter-examiner error of the 3D measurement and the validity of the
measured angles were also evaluated (32). All randomized patients were
included in the groups to which they were randomly assigned regardless
of the treatment they actually received and regardless of a deviation
from the protocol as randomized. Thus, in the analysis, the intention-totreat (ITT) approach was applied.

European Journal of Orthodontics, 2014

Table 2. Baseline variables (T0) for the unilateral and bilateral groups with mean, standard deviations (SD), and P-values. CG, control
group; EG, extraction group; PDC, palatally displaced canines; SD, standard deviation.
Unilateral PDC (patients, n=45)

Bilateral PDC (patients, n=22)

EG (n=23
PDC)

CG (n=22
PDC)

EG (n=22
PDC)

CG (n=22
PDC)

Mean SD

Mean SD

Mean SD

Mean SD

Variable at T0

11.20.9

11.41.1

P-value*

11.61.0

11.61.0

P-value*

P-value*
EG-CG

Mesioangular angle ()
Sagittal angle ()
Vertical position (mm)
Canine cusp tip-dental arch plane (mm)
Canine root apex-dental arch plane (mm)
Canine cusp tip-midline (mm)

105.25.4
98.08.1
15.92.2
1.91.2
2.21.6
9.72.2

107.79.6
101.19.5
14.92.4
2.52.0
2.71.7
9.22.7

0.182
0.232
0.178
0.300
0.224
0.322

106.17.1
100.18.6
14.62.7
3.01.0
2.81.7
9.72.6

108.07.1
99.68.7
15.02.3
3.22.2
2.61.8
9.31.8

0.371
0.337
0.597
0.626
0.654
0.597

NS
NS
NS
NS
NS
NS

Primary outcome
Significantly more PDCs erupted on the extraction site compared
with the untreated control site, with a prevalence rate of 69 and 39
per cent, respectively, (P=0.001). The mean eruption time in the EG
was 15.6months (SD 5.6) and in the CG was 18.3months (SD 5.8),
with no significant difference for the mean eruption time between
the younger (age 1011years) and the older patients (1213years)
(P = 0.238). At T2, 14 PDCs in the EG and 27 PDCs in the CG
had impairment or no changes of the canine position. These teeth
were surgically exposed and orthodontically treated. All remaining
PDCs that were followed up after T2 erupted in both groups, with
the latest at the 24month control (Table3). Of 10 PDCs in the CG
that were followed up, five deciduous canines without mobility were
extracted, while the mobile ones were left to spontaneously exfoliate.
Online supplementary figures 1 and 2 exemplify successful and
impaired changes in position of the PDCs with two patients.

Secondary outcome
Positional changes of the canine over time observed by
radiographic means
Between T0 and T1, five of six variables in the EG and three of six in
the CG improved significantly. Between T1 and T2, five variables out
of six in the EG and two in the CG improved significantly. Significant
differences in changes between the groups, in favour of the EG, were
found for three of six variables between T0 and T1 and for all variables except for the sagittal angle between T1 and T2 (Table4).

Table 3. Number of palatally displaced canines (PDCs) in the extraction (EG) and the control group (CG) that had erupted, were
impaired or had not changed at the 6month control (T1), 12month
control (T2), or after T2 (>T2)

Erupted PDCs
Impaired PDCs or
no changes

EG (N=45 PDCs)

CG (N=44 PDCs)

T1

T2

>T2

T1

T2

>T2

11
14

20

7
27

10*

*Note that five deciduous canines in the control group that were not mobile
(n=5) were extracted at T2.

The variables with significant changes between T0T1 and T1

T2 in the EG and the CG, respectively, are presented in Figure3.
In the EG, significant larger changes between T0T1 than T1T2
were observed for the distance: canine cusp tip-dental arch plane
(P = 0.0026) and canine cusp tip-midline (P = 0.0276), while
the variable: canine root apex-dental arch plane (P = 0.0085)
changed more between T1T2 than between T0T1 (Figure 3).
When changes over time were compared between the groups,
the variables for the distances: canine cusp tip-dental arch plane
(P=0.0013) and canine root apex-dental arch plane (P=0.050)
deviated more between the EG and CG between T1T2 than
between T0T1.
Root resorption of permanent adjacentteeth
None of the patients were excluded in this trial due to resorption
grades 3 and 4 of the adjacent teeth caused by the PDC either at
the start of or during the study. Thirteen patients (14 PDC) showed
root resorption grade 2 on adjacent teeth at the start of the trial,
16 patients (17 PDC) at the 6 month control and 20 patients (21
PDC) at the 12month control (Table5). Although more teeth where
resorbed in the CG than the EG, significant differences were not
found for either T1 (P=0.4218) or T2 (P=0.2123). The adjacent
teeth that had root resorption caused by the PDC were all lateral
incisors.

Discussion
The effectiveness of extracting the deciduous canine as an interceptive approach to achieve spontaneous eruption of PDC compared
with non-extraction was investigated in this prospective, randomized, clinical longitudinal trial. The findings in the study show
that extraction of the deciduous canine allows the PDCs to spontaneously correct in the majority of the cases. Significantly more radiographical changes over time were noted in the EG. We can thereby
reject the first 2 null hypotheses. Although more adjacent teeth were
resorbed at T1 and T2 in the CG than the EG, significant differences
were not found, i.e. we accept our final null hypothesis.
As patients with both bilateral and unilateral PDC were
included in the study, the tooth rather than the patient was used
as the unit of analysis. The observations in the bilateral group
could preferably have been assessed as dependent paired observations but, as the same significant results were achieved when the

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

NS, Not significant.

*P-value < 0.05 is considered statistically significant.

Significant differences between and within the groups are given in P-values.
*P-value < 0.05 is considered statistically significant.

1.27.3
1.71.6
0.91.7
0.11.3
0.61.9

0.030
0.000
0.000
0.419
0.000

1.95.9
2.71.5
1.91.5
0.21.9
2.31.5

Sagittal angle ()
Vertical position (mm)
Canine cusp tip-dental arch plane (mm)
Canine cusp apex-dental arch plane (mm)
Canine cusp tip-midline

Figure 3. Comparison of positional changes of the permanent canine

between T1T0 and T1T2 for the extraction group (EG) and control group
(CG), respectively, with mean and P-values (**0.001 and *0.05). P-values
indicate differences between T1T0 and T1T2.

main outcome for the bilateral group was assessed as independent

observations, the bilateral and unilateral PDCs were merged into
onegroup.
There was an uneven distribution of the number of patients
in the age groups, with more 1011-year-old (64 per cent) than
1213-year-old (36 per cent) patients (Table1). Apossible explanation for the greater number of younger patients in this study is that,
in Sweden, all children at the age of 10 are strictly monitored to
capture PDCs at an early age. However, it is important to consider
the overall stage of dental development of the child and not only the
chronological age because there is a poor correlation between dental
and chronological age (33). In accordance with other interceptive
studies on canine displacement, there was a larger number of female
than male patients (23, 29, 33, 34).

2.6 (5.1,
0.10)
0.7 (2.1, 3.6)
0.9 (0.3, 1.6)
0.3 (1.2, 0.6)
0.2 (0.4, 0.8)
1.7 (0.9, 2.5)
0.604
0.003
0.492
0.463
0.000

0.030
2.55.3
3.21.8
0.52.4
0.61.1
1.61.6

3.36.4

P-value* Mean SD

0.000
0.000
0.195
0.000
0.000

0.000

P-value*

EG (n=45 PDCs)

T2T1 (patients, n=67)

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

0.300
0.000
0.002
0.838
0.037

0.369

0.85.8

0.000

3.45.8

Mesioangular angle ()

Mean (95% CI)

Mean SD P-value*

P-value*

Mean SD

Differences EG-CG

CG (n=44 PDCs)

Variable

EG (n=45 PDCs)

T1T0 (patients, n=67)

Differences EG-CG

1.78.6
1.91.9
0.11.9
0.01.4
0.71.3

0.55.9
0.201
0.000
0.609
0.939
0.000

0.563

1.7(1.2, 4.7)
1.2 (0.5, 2.0)
1.1 (1.8, 0.4)
0.8 (0.2, 1.4)
0.62 (1.1, 0.1)

2.8 (5.4, 0.2)

Mean SD P-value* Mean (95% CI)

CG (n=44 PDCs)

0.249
0.002
0.001
0.012
0.017

0.034

P-value*

Table4. Positional changes over time of the permanent canine: T1T0 (6monthsbaseline) and T2T1 (12months6months) with mean, standard deviation (SD), mean differences, and 95%
confidence interval (CI), between the extraction (EG) and non-extraction (CG) site

J. Naoumova etal.
7

European Journal of Orthodontics, 2014

Table5. Root resorption of adjacent permanent teeth during T0T2 expressed in amount of teeth (N) and % of teeth. CG, control group;
EG, extraction group
EG (N=45 PDCs)
Grade 1
(no resorption)

T0
T1
T2

Grade 2

CG (N=44 PDCs)

Grade 3

38
38
37

84.5
84.5
82.2

7
7
8

15.5
15.5
17.8

0
0
0

Grade 1
(no resorption)

Grade 4
%

N
0
0
0

Grade 3

37
34
31

84.0
77.3
70.5

7
10
13

16.0
22.7
29.5

0
0
0

Grade 4
%

0
0
0

with centrally placed canines together with PDC were included

and the CG was not randomized, which could have influenced the
results. The lower success rate found in the study of Smailien etal.
(37) might be explained by the older age of the patients that were
included, as a higher age increases the probability of impactions.
Some previous studies (27, 28, 38) defined successful outcome as
fully erupted canines, thus permitting bracket positioning for final
arch alignment when needed or as defined by Bazargani etal. (29)
in an esthetical acceptable location in the dental arch. This variation in definitions of successful outcome could be another reason for
the different success rates reported. In this clinical trial, canines that
emerged through the gingiva were considered successful. In addition,
in this study, only an ITT approach was used when the outcome was
assessed, which may be another explanation for the differences in
the successrate.
Significantly more changes for both angular and distance variables were found between both T0T1 and T1T2 in the EG, which
was not surprising because the successful outcome was higher in the
EG than in theCG.
In the EG, the movement of the cusp-tip in relation to the dental arch and in relation to the midline was larger during the first
6 months after extraction, while the movement of the apex was
larger between 6 and 12 months (Figure 3). These results support
Ericson and Kurol (23) finding that improvement of the position of
the PDCs can already be seen after 6months.
The prognosis for successful orthodontic end results when adults
are treated for PDCs is poorer than in younger patients and the
prognosis worsens with age (1). Furthermore, the duration of orthodontic treatment to address impacted canines correlated with age
in that the treatment duration increases with increased age (1, 39).
Permanent canines that have been impacted for many years undergo
pathological changes that prevent their eruption even when all other
factors are favourable (40). The risk for developing ankylosis either
a priori or during treatment is higher the older the patient is (40).
We, therefore, considered it unethical to follow-up patients longer
than 1year without making any individual treatment plan, especially
as data from this study shows a tendency toward more resorbed
adjacent teeth in the CG at T2 than at T0 and as more canines had
erupted in the EG during the first 12months. This was also the reason for extracting the remaining deciduous canines in the CG that
were not mobile atT2.
The frequency of root resorption caused by PDCs has been
reported in the literature to be around 50 per cent of which the
majority are lateral incisors (4144). In this study, however, 23.5
per cent showed resorptions, and only on lateral incisors. The low
figures may be explained by that this study comprise of prospective randomized design with the exclusion criteria: root resorption
of grades 3 and 4, while the above-mentioned studies either had a

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

In a Cochrane systematic review that assessed the effect of

extracting the deciduous canine on the eruption of PDC, several
observations for what should be included in future studies were
discussed (25). The most important factors were concealed random
allocation, blind assessment, sample size, and correct statistical
analysis. We tried to fulfil these criteria in this study, but it was not
possible to blind the patients to the allocated intervention except
at baseline, where the radiographic measurements were blinded. It
was not possible to block out the deciduous canine space on the
radiographs on the 3D radiographs, as can easily be done on panoramic x-ray. An alternative would have been an assessor who had no
knowledge of the study. This was not possible in this study, however,
as a new 3D measurement method to evaluate the canine position
had to be developed together with the oral radiologist (32).
In comparison with previously published studies where panoramic x-ray were used for diagnosis of PDC and assessment of the
outcome, this trial is to our knowledge the first one to assess the
effect of extracting the deciduous canine in patients with PDC using
3D images. Amore accurate diagnosis of the canine position and 3D
assessment of the canine movements are possible with 3D images. In
addition, small resorptions of the adjacent teeth caused by the PDC
can be detected.
Several RCT studies discuss the topic of interceptive treatment
of PDCs, both with and without a combination of different appliances such as cervical headgear (HG) (34), rapid maxillary expansion (RME) (35), RME followed by HG (36), extraction of both
the deciduous canine and the first deciduous molar (28), RME followed by transpalatal arch (TPA) (27), extraction of the deciduous
canine followed by TPA (26), or extraction of the deciduous canine
on one side in patients with bilateral PDCs (29). These studies all
point toward the benefit of the interceptive treatment. However,
some weaknesses are noted, for example questionable power analysis (2628), questionable randomization, and the unequal descriptive statistics at baseline between the different groups (26) and
missing allocation concealment concerning unilateral and bilateral
PDCs (26, 27), and uncertain diagnosing of PDC from only panoramic radiography (28). The results of this study showed that significantly (P = 0.001) more canines erupted on the extraction site
(69 per cent) compared with the control site (39 per cent). These
findings are comparable and confirm the results of previous studies
that presented successful results between 62 and 67 per cent on the
extraction site and 28 and 42 per cent on the non-extraction site
(26, 29, 33, 34). Some studies present higher success rates of around
80 per cent (23, 28) or a lower success rate of 42 per cent (37). The
high success rate in the prospective uncontrolled study of Ericson
and Kurol (23) can be explained by that the authors having counted
both canine eruption and improvement of the canine eruption path
as a successful outcome. In the study by Bonetti etal. (28), patients

Grade 2

J. Naoumova etal.

Limitations
As no CBCTs were taken, for ethical reasons, of the PDCs that
were erupted at T2, imputation values were used as an alternative
of excluding these cases. Using the imputation values instead of considering these patients as dropouts is, in our opinion, an advantage,
as those teeth that had erupted spontaneously probably are those in
best position and excluding them would have biased the results.
However, as imputation values of normally erupting canines at T2,
from the unilateral patient group were used in 15 patients, this
might have affected the results of the angular and positional changes
between T1 and T2. To find out how the results might change using
imputation values of normally positioned canines, a comparison
was made between the imputed values and values from the bilateral
patient group that had one PDC under eruption while the other was
still palatally displaced i.e. x-rays were taken at T2. Seven spontaneously erupting PDCs were identified and compared. No significant
differences were found either for the angular or for the positional
changes between the erupted PDCs and those with normal position.
However, an imputation can always give uncertainty in the results,
therefore the changes between T1 and T2 should be interpreted with
some caution.

Generalization
The results of the main sample obtained from the present sample can be
generalized only in a Caucasian population aged 10-13 years and in the
case that the exclusion criteria are met. The use of imputation values as
mentioned above, may curtail the generalization of the results regarding
the positional changes of the canine between T1 and T2. In addition, due
to the selective exclusion of PDCs resorbing adjacent teeth with grades
3 and 4 at the start and during the trial, may limit its representativeness, and thus limit the generalization of the frequence of root resorption
caused by PDCs in a general population.

Conclusions
Extraction of the deciduous canine in patients with PDC is an
effective interceptive approach: 69 per cent of the permanent
canines erupted when the deciduous canine was extracted, while
39 per cent erupted in the non-EG. The mean eruption time was
15.6months in the EG and 18.3months in the CG.
Significantly more angular and distance changes occurred in the
EG compared with the CG.
In the EG, the movement of the cusp-tip in relation to the dental
arch and in relation to the midline was larger during the first
6 months after extraction, while the movement of apex was
larger between 6 and 12months.
Canines with an improved position at the 12 month control
should be followed up with a clinical and if necessary a radiographic examination, as spontaneous eruption after 12months
still is possible.
No significant differences in root resorption of adjacent teeth
was found at T2 between the CG and the EG.

Supplementary material
Supplementary material is available at European Journal of
Orthodontics online.

Funding
Local Research and Development Board for Gothenburg and Sdra
Bohusln; Health and Medical Care Committee of the Regional
Executive Board for Vstra Gtaland Region.

Acknowledgements
This work is dedicated to Prof. Jri Kurol who suddenly and sadly passed away
during the work of this study. The authors wish to thank the general practitioners and the consulting orthodontists at the Department of Orthodontics,
University Clinics of Odontology, Gothenburg, Sweden, for identifying and
inviting potential patients to participate in the study.

References
1. Becker, A. and Chaushu, S. (2003) Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines.
American Journal of Orthodontics and Dentofacial Orthopedics, 124,
509514.
2. Stewart, J.A., Heo, G., Glover, E.K., Williamson, C.P., Lam, W.N.E. and
Major, W.P. (2001) Factors that relate to treatment duration for patients
with palatally impacted maxillary canines. American Journal of Orthodontics and Dentofacial Orthopedics, 119, 216225.
3. Bazargani, F., Magnuson, A., Dolati, A. and Lennartsson, B. (2013) Palatally displaced maxillary canines: factors influencing duration and cost of
treatment. European Journal of Orthodontics, 35, 310316.

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

retrospective material or included only patients that were selected for

a CT imaging. Furthermore, the patients in this study were younger.
Ericson and Kurol (41) found that the peak frequency of root resorption is between 11 and 12years of age. However, as the authors also
mention in their article, the selection and complexity of the material
including more severe cases might have affected the results.
The mean eruption time in the EG was shorter than in the CG
(15.6 versus 18.3months). In total, 30 PDCs erupted after 12months:
therefore, canines with an improved position after 1year follow-up
should, therefore, be clinically and, if necessary, radiographically followed up as spontaneous eruption after 12months is still possible.
Ten of 30 PDCs that erupted after 12months were in the CG, while
five deciduous canines were extracted at T2, as these canines were
not mobile. If these five extracted deciduous canines are excluded,
the mean eruption time in the CG increased to 19.34.7months.
According to this study, early diagnosis of PDCs and extraction of the deciduous canine as an interceptive approach is recommended. The protocol with systematic use of CBCT in this trial was
designed so as to make it possible to draw out the results. However,
for everyday diagnostics and follow-up of uneventful cases of lost
canines, we suggest the use of 2D imaging. Furthermore, as some
permanent canines erupt without extracting the deciduous canine
first and some permanent canines do not erupt in spite of extraction
(See online supplementary figure2), the question arises as to whether
it is possible to distinguish these cases. Thus, unnecessary interceptive extractions may be avoided or perhaps a decision in favour of
surgical exposure of the impacted canine immediately without preceding interceptive extraction of the deciduous canine can bemade.
Because extraction of the deciduous canine or surgical exposure
might be the childs first experience of invasive dental treatment, it
is important that the child does not develop dental fear as a consequence of the intervention. Although Naoumova etal. (45) showed
that the experience of pain and discomfort during and after extraction
of the deciduous canine in patients with PDC was low, 42 per cent
of the children in their study nevertheless used analgesics, indicating
post-extraction pain. Therefore, some surgical interventions may be
avoided by predicting and calculating cut-off points for a successful
outcome. A more detailed determination of predictors and cut-off
points for successful outcome will be analysed in part II of this study.

10

26. Baccetti, T., Sigler, L.M., McNamara, J.A., Jr. (2011) An RCT on treatment
of palatally displaced canines with RME and/or a transpalatal arch. European Journal of Orthodontics, 33, 601607.
27. Sigler, M.L., Baccetti, T. and McNamara, J., Jr. (2011) Effect of rapid maxillary expansion and transpalatal arch treatment associated with deciduous canine extraction on the eruption of palatally displaced canines: a
2-center prospective study. American Journal of Orthodontics and Dentofacial Orthopedics, 139, e235e244.
28. Bonetti, G.A., Zanarini, M., Incerti, P.S., Marini, I. and Gatto, M.R. (2011)
Preventive treatment of ectopically erupting maxillary permanent canines
by extraction of deciduous canines and first molars: a randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics,
139, 316323.
29. Bazargani, F., Magnuson, A. and Lennartsson, B. (2014) Effect of interceptive extraction of deciduous canine on palatally displaced maxillary canine: a
prospective randomized controlled study. The Angle Orthodontist, 84, 310.
30. Clark C. (1909) A method of ascertaining the position of uneruptedteeth by
means of film radiographs. Proc R Soc Med, 3, 8790.
31. Ericson, S. and Kurol, J. (2000) Incisor root resorptions due to ectopic
maxillary canines imaged by computerized tomography: a comparative
study in extracted teeth. The Angle Orthodontist, 70, 276283.
32. Naoumova, J., Kjellberg, H. and Palm, R. (2014) Cone-beam computed
tomography for assessment of palatal displaced canine position. The
Angle Orthodontist, 84, 459466.
33. Power, S.M. and Short, M.B. (1993) An investigation into the response of
palatally displaced canines to the removal of deciduous canines and an
assessment of factors contributing to favourable eruption. British Journal
of Orthodontics, 20, 215223.
34. Baccetti, T., Leonardi, M. and Armi, P. (2008) A randomized clinical study
of two interceptive approaches to palatally displaced canines. European
Journal of Orthodontics, 30, 381385.
35. Baccetti, T., Mucedero, M., Leonardi, M. and Cozza, P. (2009) Interceptive
treatment of palatal impaction of maxillary canines with rapid maxillary
expansion: a randomized clinical trial. American Journal of Orthodontics
and Dentofacial Orthopedics, 136, 657661.
36. Armi, P., Cozza, P. and Baccetti, T. (2011) Effect of RME and headgear
treatment on the eruption of palatally displaced canines: a randomized
clinical study. The Angle Orthodontist, 81, 370374.
37. Smailien, D., Sidlauskas, A., Lopatien, K., Guzeviien, V. and Juodbalys,
G. (2011) Factors affecting self-eruption of displaced permanent maxillary
canines. Medicina (Kaunas), 47, 163169.
38. Leonardi, M., Armi, P., Franchi, L. and Baccetti, T. (2004) Two interceptive approaches to palatally displaced canines: a prospective longitudinal
study. The Angle Orthodontist, 74, 581586.
39. Zuccati, G., Ghobadlu, J., Nieri, M. and Clauser, C. (2006) Factors associated with the duration of forced eruption of impacted maxillary canines:
a retrospective study. American Journal of Orthodontics and Dentofacial
Orthopedics, 130, 349356.
40. Azaz, B. and Shteyer, A. (1978) Resorption of the crown in impacted maxillary canine. A clinical, radiographic and histologic study. International
Journal of Oral Surgery, 7, 167171.
41. Ericson, S. and Kurol, P.J. (2000) Resorption of incisors after ectopic eruption of maxillary canines: a CT study. The Angle Orthodontist, 70, 415423.
42. Walker, L., Enciso, R. and Mah, J. (2005) Three-dimensional localization
of maxillary canines with cone-beam computed tomography. American
Journal of Orthodontics and Dentofacial Orthopedics, 128, 418423.
43. Bjerklin, K. and Ericson, S. (2006) How a computerized tomography
examination changed the treatment plans of 80 children with retained
and ectopically positioned maxillary canines. The Angle Orthodontist,
76, 4351.
44. Liu, D.G., Zhang, W.L., Zhang, Z.Y., Zhang, W.L., Wu, Y.T. and Ma, X.C.
(2008) Localization of impacted maxillary canines and observation of
adjacent incisor resorption with cone-beam computed tomography. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 105, 9198.
45. Naoumova, J., Kjellberg, H. and Mohlin, B. (2012) Pain, discomfort, and use of
analgesics following the extraction of primary canines in children with palatally
displaced canines. International Journal of Paediatric Dentistry, 22, 1726.

Downloaded from http://ejo.oxfordjournals.org/ at Universiti Malaya on October 6, 2014

4. Ericson, S. and Kurol, J. (1987) Incisor resorption caused by maxillary

cuspids. Aradiographic study. The Angle Orthodontist, 57, 332346.
5. Rimes, R.J., Mitchell, C.N. and Willmot, D.R. (1997) Maxillary incisor
root resorption in relation to the ectopic canine: a review of 26 patients.
European Journal of Orthodontics, 19, 7984.
6. Saldarriaga, J.R. and Patio, M.C. (2003) Ectopic eruption and severe root
resorption. American Journal of Orthodontics and Dentofacial Orthopedics, 123, 259265.
7. Thilander, B. and Myrberg, N. (1973) The prevalence of malocclusion in
Swedish schoolchildren. Scandinavian Journal of Dental Research, 81,
1221.
8. Shah, R.M., Boyd, M.A. and Vakil, T.F. (1987) Studies of permanent tooth
anomalies in 7886 Canadian individuals. I: impacted teeth. Journal of
Canadian Dental Association, 44, 262264.
9. Grover, P.S. and Lorton, L. (1985) The incidence of unerupted permanent
teeth and related clinical cases. Oral Surgery, Oral Medicine, and Oral
Pathology, 59, 420425.
10. Becker, A., Smith, P. and Behar, R. (1981) The incidence of anomalous
maxillary lateral incisors in relation to palatally-displaced cuspids. The
Angle Orthodontist, 51, 2429.
11. Becker, A., Zilberman, Y. and Tsur, B. (1984) Root length of lateral incisors
adjacent to palatally-displaced maxillary cuspids. The Angle Orthodontist, 54, 218225.
12. Peck, S., Peck, L. and Kataja, M. (1994) The palatally displaced canine
as a dental anomaly of genetic origin. The Angle Orthodontist, 64, 249
256.
13. Peck, S., Peck, L. and Kataja, M. (1995) Sense and nonsense regarding
palatal canines. The Angle Orthodontist, 65, 99102.
14. Peck, S., Peck, L. and Kataja, M. (1996) Prevalence of tooth agenesis and
pegshaped maxillary lateral incisor associated with palatally displaced
canine (PDC) anomaly. American Journal of Orthodontics and Dentofacial Orthopedics, 110, 441443.
15. Pirinen, S., Arte, S. and Apajalahti, S. (1996) Palatal displacement of

canine is genetic and related to congenital absence of teeth. Journal of
Dental Research, 75, 17421746.
16. Bishara, E.S. (1998) Clinical management of impacted maxillary canines.
Seminars in Orthodontics, 4, 8798.
17. Jacobs, G.S. (1999) Localization of the unerupted maxillary canine: how
to and when to. American Journal of Orthodontics and Dentofacial
Orthopedics, 115, 314322.
18. Ngan, P., Hornbrook, R. and Weaver, B. (2005) Early timely management
of ectopically erupting maxillary canines. Seminars in Orthodontics, 11,
152163.
19. Botticelli, S., Verna, C., Cattaneo, P.M., Heidmann, J. and Melsen,

B. (2011) Two- versus three-dimensional imaging in subjects with
unerupted maxillary canines. European Journal of Orthodontics, 33,
344349.
20. Haney, E., Gansky, S.A., Lee, J.S., Johnson, E., Maki, K., Miller, A.J. and
Huang, J.C. (2010) Comparative analysis of traditional radiographs and
cone-beam computed tomography volumetric images in the diagnosis and
treatment planning of maxillary impacted canines. American Journal of
Orthodontics and Dentofacial Orthopedics, 137, 590597.
21. Alqerban, A., Jacobs, R., Fieuws, S. and Willems, G. (2011) Comparison
of two cone beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root
resorption. European Journal of Orthodontics, 33, 93102.
22. Buchner, H.J. (1936) Root resorption caused by ectopic eruption of maxillary cuspid. International Journal of Orthodontia, 22, 12361237.
23. Ericson, S. and Kurol, J. (1988) Early treatment of palatally erupting maxillary canines by extraction of the primary canines. European Journal of
Orthodontics, 10, 283295.
24. Naoumova, J., Kurol, J. and Kjellberg, H. (2011) A systematic review of
the interceptive treatment of palatally displaced maxillary canines. European Journal of Orthodontics, 33, 143149m.
25. Parkin, N., Furness, S., Shah, A., Thind, B., Marshman, Z., Glenroy,

G., Dyer, F. and Benson, P.E. (2012) Extraction of primary (baby) teeth
for unerupted palatally displaced permanent canine teeth in children.
Cochrane Database of Systematic Reviews, 12, CD004621.

European Journal of Orthodontics, 2014