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
impacted tooth, followed by orthodontic traction to guide and
align it into the dental arch. Bone loss, root resorption, and
gingival recession around the treated teeth are some of the most
common complications.
Early diagnosis and intervention could save the time, expense,
and more complex treatment in the permanent dentition.
Tooth impaction can be defined as the infraosseous position
of the tooth after the expected time of eruption, whereas the
anomalous infraosseous position of the canine before the
expected time of eruption can be defined as a displacement.
Most of the time, palatal displacement of the maxillary canine
results in impaction.[1,2]
With early detection, timely interception and well-managed
surgical and orthodontic treatment, impacted maxillary canines
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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
canines can be treated successfully.
Prevalence and Etiology
Maxillary canines are the most commonly impacted teeth, second
only to third molars.[2] Maxillary canine impaction occurs in
approximately 2% of the population and is twice as common in
females as it is in males. The incidence of canine impaction in the
maxilla is more than twice that in the mandible. Of all patients who
have impacted maxillary canines, 8% have bilateral impactions.[3]
Approximately one-third of impacted maxillary canines are located
labially and two-thirds are located palatally.[4,5] Canine impaction
can be caused by various factors. The exact etiology of palatally
displaced maxillary canines is unknown. The results of Jacobys[6]
study showed that 85% of palatally impacted canines had sufficient
space for eruption, whereas only 17% of labially impacted canines
had sufficient space. Therefore, arch length discrepancy is thought
to be a primary etiologic factor for labially impacted canines.[5]
Several etiologic factors for canine impactions have been proposed:
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

Box 1: Etiologic factors associated with impacted canines
Localized
Tooth sizearch length discrepancies
Failure of the primary canine root to resorb
Prolonged retention or early loss of the primary canine
Ankylosis of the permanent canine
Cyst or neoplasm
Dilaceration of the root
Absence of the maxillary lateral incisor
Variation in root size of the lateral incisor (peg-shaped lateral
incisor)
Variation in timing of lateral incisor root formation
Iatrogenic factors
Idiopathic factors
Systemic
Endocrine deficiencies
Febrile diseases
Irradiation
Genetic
Heredity
Malposed tooth germ
Presence of an alveolar cleft
incisor, which serves as a guide, and if the root of the lateral incisor
is absent or malformed, the canine will not erupt.[8]
The genetic theory points to genetic factors as a primary origin of
palatally displaced maxillary canines and includes other possibly
associated dental anomalies, such as missing or small lateral
incisors.[9] Baccetti[10] reported that palatally impacted maxillary
canines are genetically reciprocally associated with anomalies
such as enamel hypoplasia, infraocclusion of primary molars,
aplasia of second premolars, and small maxillary lateral incisors.
Sequelae of Canine Impaction
Shafer et al.[11] suggested the following sequelae for canine
impaction:
1. Labial or lingual malpositioning of the impacted tooth,
2. Migration of the neighboring teeth and loss of arch length,
3. Internal resorption,
4. Dentigerous cyst formation,
5. External root resorption of the impacted tooth, as well as
the neighboring teeth,
6. Infection particularly with partial eruption, and
7. Referred pain and combinations of the above sequelae.
It is estimated that in 0.71% of children in the 1013 year
age group, permanent incisors have resorbed because of the
ectopic eruption of maxillary canines.[12] On the other hand,
the presence of the impacted canine may cause no untoward
effects during the lifetime of the person.
These potential complications, as well as others that will be
detailed later, emphasize the need for close observation of the
development and eruption of these teeth during routine
periodic dental examination of the growing child.
Diagnosis of Canine Impaction
The diagnosis of canine impaction is based on both clinical and
radiographic examinations.
Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012 Supplement 2 - Part 2 S235
Manne, etal.: Orthodontic management of impacted canines
Clinical Evaluation
It has been suggested that the following clinical signs might be
indicative of canine impaction:[3]
1. Delayed eruption of the permanent canine or prolonged
retention of the deciduous canine beyond 1415 years of age,
2. Absence of a normal labial canine bulge,
3. Presence of a palatal bulge, and
4. Delayed eruption, distal tipping, or migration (splaying) of
the lateral incisor.
According to Ericson and Kurol,[12] the absence of the canine
bulge at earlier ages should not be considered as indicative
of canine impaction. In their evaluation of 505 schoolchildren
between 10 and 12 years of age, they found that 29% of the
children had nonpalpable canines at 10 years, but only 5% had it
at 11 years, whereas at later ages only 3% had nonpalpable canines.
Therefore, for an accurate diagnosis, the clinical examination
should be supplemented with a radiographic evaluation.
Radiographic Evaluation
Although various radiographic exposures including occlusal
films, panoramic views, and lateral cephalograms can help in
evaluating the position of the canines, in most cases, periapical
films are uniquely reliable for that purpose.[3,13]
Periapical films
A single periapical film provides the clinician with a two-
dimensional representation of the dentition. In other words,
it would relate the canine to the neighboring teeth both
mesiodistally and superoinferiorly. To evaluate the position of
the canine buccolingually, a second periapical film should be
obtained by one of the following methods.
Tube-shift technique or Clarks rule or (SLOB) rule
Two periapical films are taken of the same area, with the
horizontal angulation of the cone changed when the second film
is taken. If the object in question moves in the same direction
as the cone, it is lingually positioned. If the object moves in the
opposite direction, it is situated closer to the source of radiation
and is therefore buccally located.
Buccal-object rule
If the vertical angulation of the cone is changed by approximately
20 in two successive periapical films, the buccal object will move
in the direction opposite to the source of radiation. On the other
hand, the lingual object will move in the same direction as the
source of radiation. The basic principle of this technique deals
with the foreshortening and elongation of the images of the films.
Occlusal films
Also help to determine the buccolingual position of the impacted
canine in conjunction with the periapical films, provided that
 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
radiation comes from behind the patient; thus, the movements
are reversed for position.
CT/CBCT
Clinicians can localize canines by using advanced three-
dimensional imaging techniques. Cone beam computed
tomography (CBCT) can identify and locate the position of
impacted canines accurately. By using this imaging technique,
dentists also can assess any damage to the roots of adjacent
teeth and the amount of bone surrounding each tooth. However,
increased cost, time, radiation exposure, and medicolegal issues
associated with using CBCT limit its routine use.
The proper localization of the impacted tooth plays a crucial
role in determining the feasibility of as well as the proper
access for the surgical approach and the proper direction for
the application of orthodontic forces.
Interceptive Treatment
When the clinician detects early signs of ectopic eruption of the
canines, an attempt should be made to prevent their impaction
and its potential sequelae. Selective extraction of the deciduous
canines as early as 8 or 9 years of age has been suggested by
Williams as an interceptive approach to canine impaction in
Class I uncrowded cases. Ericson and Kurol[12] suggested that
removal of the deciduous canine before the age of 11 years will
normalize the position of the ectopically erupting permanent
canines in 91% of the cases if the canine crown is distal to the
midline of the lateral incisor. On the other hand, the success
rate is only 64% if the canine crown is mesial to the midline of
the lateral incisor [Figure 1].[12]
Treatment alternatives
Each patient with an impacted canine must undergo a
comprehensive evaluation of the malocclusion. The clinician
should then consider the various treatment options available
for the patient, including the following:[3]
1. No treatment if the patient does not desire it. In such a case,
the clinician should periodically evaluate the impacted tooth
S236 Journal of Pharmacy and Bioallied Sciences Vol 4 August 2012 Supplement 2 - Part 2
Figure 1: Schematic illustration showing the normalization rates of
the maxillary canine after extraction of the primary canine when the
permanent maxillary canine is located mesially and distally to the
midline of the lateral incisor
for any pathologic changes. It should be remembered that
the long-term prognosis for retaining the deciduous canine
is poor, regardless of its present root length and the esthetic
acceptability of its crown. This is because, in most cases,
the root will eventually resorb and the deciduous canine will
have to be extracted.
2. Autotransplantation of the canine.
3. Extraction of the impacted canine and movement of a first
premolar in its position.
4. Extraction of the canine and posterior segmental osteotomy to
move the buccal segment mesially to close the residual space.
5. Prosthetic replacement of the canine.
6. Surgical exposure of the canine and orthodontic treatment
to bring the tooth into the line of occlusion. This is obviously
the most desirable approach.
When to Extract an Impacted Canine
It should be emphasized that extraction of the labially
erupting and crowded canine, unsightly as this tooth may
look, is contraindicated. Such an extraction might temporarily
improve the esthetics, but may complicate and compromise the
orthodontic treatment results, including the ability to provide
the patient with a functional occlusion. The extraction of the
canine, although seldom considered, might be a workable option
in the following situations:[3]
1. If it is ankylosed and cannot be transplanted,
2. If it is undergoing external or internal root resorption,
3. If its root is severely dilacerated,
4. If the impaction is severe (e.g., the canine is lodged between
the roots of the central and lateral incisors and orthodontic
movement will jeopardize these teeth),
5. If the occlusion is acceptable, with the first premolar in the
position of the canine and with an otherwise functional
occlusion with well-aligned teeth,
6. If there are pathologic changes (e.g., cystic formation,
infection), and
7. If the patient does not desire orthodontic treatment.
 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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Source of Support: Nil, Conflict of Interest: None declared.
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