CASE REPORT
Treatment of a patient with Class II
malocclusion, impacted maxillary canine
with a dilacerated root, and peg-shaped
lateral incisors
Eve Tauschea and Winfried Harzerb
Dresden, Germany
The maxillary canines are important teeth in terms of esthetics and function. This case report describes the
orthodontic treatment of a 12-year-old girl whose Class II malocclusion was complicated by an impacted
maxillary canine and peg-shaped lateral incisors. Despite dilaceration of the root, the impacted canine was
brought into alignment. The peg-shaped lateral incisors were extracted, and the spaces were closed,
resulting in favorable esthetics and good occlusion in the long term. (Am J Orthod Dentofacial Orthop 2008;
133:762-70)
T
he maxillary canines are important teeth in
terms of esthetics and function. The likelihood
of their failing to erupt or becoming impacted
ranges between 1% and 3%.1
The causes of canine impaction can correlate with
other dental anomalies, and they can be due to local
factors or a polygenetic, multifactorial inheritance.
Local factors are tooth size-arch length discrepancies,
prolonged retention or early loss of the deciduous
canine, abnormal tooth bud position, alveolar cleft,
dilaceration of the root, and idiopathic conditions with
no apparent cause.2 The absence of the maxillary lateral
incisors or small or peg-shaped lateral incisors corre-
lates closely with maxillary canine palatal impaction
(with an incidence 2.4 times higher than in the general
population).3-5
DIAGNOSIS AND ETIOLOGY
A 12-year-old girl was referred by an oral surgeon
for a second consultation. The original diagnosis was to
extract the impacted right canine because of a dilacer-
ated root. Her father had peg-shaped maxillary lateral
incisors. Her brother and older sister had been treated
for excess overjet.
From the Technical University of Dresden, Dresden, Germany.
a
Assistant medical director, Orthodontic Department.
b
Head, Orthodontic Department.
Reprint requests to: Eve Tausche, Technical University of Dresden, Poliklinik
fr Kieferorthopdie, Fetscherstrasse 74, 01347 Dresden, Germany; e-mail,
Eve.Tausche@uniklinikum-dresden.de.
Submitted, April 2006; revised and accepted, September 2006.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.09.052
762
Extraoral analysis showed a concave face and a
retrognathic mandible (Fig 1). She had a mild lisp and
was unhappy about the appearance of her teeth. The
patient was in the second stage of dentition, and her
oral hygiene was excellent.
Intraoral examination showed peg-shaped maxil-
lary lateral incisors and a narrow maxilla with an
unerupted right canine and loss of space for this
tooth (Figs 2 and 3). She also had a midline devia-
tion. Loss of the deciduous canine can cause a
midline shift and allow mesial drift of the permanent
right first molar. Mild spacing was present in the
mandibular arch, and her teeth had erupted into fairly
good alignment with no deficiency in arch length.
Radiographic examination showed complete denti-
tion except for the mandibular left and right third
molars (Fig 4). The maxillary right canine was
impacted, with almost complete root formation. A
maxillary occlusal radiograph confirmed the palatal
position of the impacted tooth. It was obvious that
the impacted right canine was positioned high and
had a dilacerated root. The patient had a Class II
molar relationship with overjet of 7 mm and overbite
of 4 mm. Functionally, the mandible showed pro-
nounced sagittal anterior advancement. The mandi-
ble and the maxilla were retrognathic in relation to
the cranial base. The ANB angle was 5.5. The
cephalometric tracing showed a vertical growth pat-
tern (Fig 5, Table).
In this patient, the etiology of the impaction was
probably the early loss of the deciduous canine, tooth
size-arch length discrepancies, malformed lateral inci-
sors, and dilaceration of the root.
American Journal of Orthodontics and Dentofacial Orthopedics Tausche and Harzer 763
Volume 133, Number 5

Fig 1. Facial views at the beginning of treatment (patients age, 12 years).

Fig 2. Intraoral views at the beginning of treatment.

TREATMENT OBJECTIVES molar relationship. The benefit of this treatment plan

Despite the dilaceration of the root, the goals
were to expose and align the impacted right canine,
expand the maxillary arch, and correct the antero-
posterior relationship. We decided to extract the
peg-shaped maxillary lateral incisors and obtain
anterior symmetry with bilateral canine substitutions.
In the mandibular dentition, the objectives were
to align the teeth and close the mild spacing. The
occlusal objectives were to improve the intercuspa-
tion of the posterior teeth and decrease the overjet.
Since the mandibular arch would be treated without
extractions, the final occlusion would be a Class II
was to avoid restoration of the maxillary lateral
incisors. Furthermore, it is easier to achieve an
esthetically pleasing result in the anterior region,
resulting in symmetrical tooth size and shape. Ex-
traction of the peg-shaped lateral incisors also facil-
itated midline correction and ideal intercuspation of
the posterior teeth.
A disadvantage might be in the final esthetics
vis--vis tooth shape, color, and sizefactors that
are often uncertain in canine-substitution cases.
To optimize the esthetic and functional occlusion,
we planned to build up the maxillary canines with
764 Tausche and Harzer American Journal of Orthodontics and Dentofacial Orthopedics
May 2008

Fig 3. Pretreatment dental casts.

Fig 5. Pretreatment cephalometric tracing.

Fig 4. Pretreatment panoramic radiograph, with en-

larged section to show the position of the impacted
canine.
American Journal of Orthodontics and Dentofacial Orthopedics Tausche and Harzer 765
Volume 133, Number 5

Table. Pretreatment and posttreatment cephalometric

measurements
Pretreatment Posttreatment

Skeletal analysis
SNA angle 72.8 71.1
SNB angle 67.3 68.5
ANB angle 5.5 2.6
NL-NSL 12.2 8.4
ML-NSL 43.7 40.8
ML-NL 31.6 32.5 Fig 6. Maxillary occlusal view showing the sectional
SNPg 69.8 70.4 wire fixed at the quad-helix.
NSBa 137.2 135.3
Gonial angle 132.2 132
Face height ratio 90.9% 83.6%
Dentition analysis
plete midline correction; also, the anterior esthetics
Maxillary incisor to NA 21.5 26.9 could be compromised because of variations in tooth
Maxillary incisor to NL 73.6 73.6 size and shape and the difficulty in matching the left
Mandibular incisor to NB 25.7 23.6 canine with the restored right lateral incisor.
Mandibular incisor to ML 85.3 85.7
Interincisal angle 127.3 126.9 TREATMENT PROGRESS
Soft-tissue analysis
Upper lip to E-line 6.7 mm 5.8 mm The impacted canine was surgically exposed. A
Lower lip to E-line 3.4 mm 3.6 mm bracket was bonded, and a stainless steel ligature wire
was braided from this bracket. A month later, the
maxillary arch was expanded with a quad-helix appli-
hybrid composite and bleach them after orthodontic ance. To allow the canines vertical mobility and
treatment. minimize undesirable reactions of the anchor teeth, the
quad-helix had an extra palatal branch (0.017 0.025-
TREATMENT ALTERNATIVES in, beta-titanium alloy) (Fig 6). To move the impacted
Our treatment plan involved the surgical exposure tooth, we applied a force of 50 to 60 g (2 oz).
of the impacted right canine. Standard edgewise appliances (0.018-in slot) were
Especially because of the high position and the placed in both arches, and normal leveling and initial
dilacereated canine root, other options were considered, alignment were achieved. After we placed a standard
in case the canine would not move into the position stainless steel wire (0.016 0.022 in), the left peg-
after the procedure. shaped incisor was extracted, and the space was closed
Another option would have been to extract the from the distal aspect. The maxillary right lateral
impacted canine and the left lateral incisor, correct the incisor could not be extracted until we confirmed that it
midline, build up the peg-shaped right incisor to match would be possible to move the impacted canine. The
the contralateral canine, and substitute premolars for the maxillary expansion was completed in 6 months. Due
canines on both sides. The advantage of that treatment is to sufficient transverse maxillary width, anterior man-
its brevity, resulting in much less stress for the patient. dibular advancement could be obtained. Thus, overjet
The disadvantages are difficulties in achieving a com- decreased to 3 mm. The left canine and the left

Fig 7. Intraoral views after standard stainless steel wire (0.016 0.022 in) was placed. The left
peg-shaped incisor was extracted and space closed. Expansion of the maxillary bone was
completed. The left canine and left posterior segment were protracted. Overjet was 3 mm.
766 Tausche and Harzer
Fig 8. Progress periapical radiograph, 14 months after
start of treatment. The impacted right canine was
moved vertically.
posterior segments were protracted. The midline shift
was almost eliminated (Fig 7). After 14 months of
treatment, the impacted tooth was moved vertically
(Fig 8). After transverse expansion and retention, the
quad-helix was substituted by a transpalatal bar. With a
segmental wire attached to the transpalatal bar, the
impacted canine was moved farther (Fig 9).
As soon as the impacted canine was palpable, the
right lateral incisor could be extracted. Since it was so
important to move the canine crown occlusally and
labially, a buccal auxiliary spring (0.017 0.025-in
beta-titanium alloy) was fixed onto the bracket of the
right canine (Fig 10). Gradually, the canine was moved
into its proper postition. Mandibular arch treatment was
uneventful, and we used routine archwire sequences.
After leveling and aligning the mandibular arch, elas-
tics were attached to correct the Class II occlusion.
Despite the dilacerated canine root, the impacted
tooth was moved and integrated into alignment (Fig
Fig 10. Buccal auxiliary spring (0.017 0.025-in beta-titanium alloy) was fixed onto the bracket of
the right canine.
American Journal of Orthodontics and Dentofacial Orthopedics
May 2008
Fig 9. Maxillary occlusal view. Sectional wire was at-
tached to the transpalatal bar. The impacted canine was
moved farther.
11). Archwires were sectioned to allow the occlusion to
settle; then the patient was debonded. Retention con-
sisted of maxillarily and mandibular removable re-
tainers.
To improve esthetics, we recommended recontour-
ing and bleaching the maxillary canines, but the patient
refused. Otherwise, compliance was excellent, and
treatment was completed in 36 months.
RESULTS
Overall, favorable esthetics and excellent occlusal
results were obtained. Significant improvement in the
patients facial balance was noted, and we achieved a
stable bilateral Class II occlusion, a well-intercuspated
occlusion, and ideal overjet and overbite (Figs 12-14).
The peg-shaped lateral incisors were extracted and
the space closed by substituting the canines. Despite the
dilacerated root, the impacted maxillary right canine
could be aligned, and the maxillary left posterior teeth
were bodily moved. The midline was corrected. The
resulting occlusion was a Class II molar relationship. In
the maxilla, the anteroposterior, transverse, and vertical
relationships were maintained, and forward rotation of
the mandible was observed. The posttreatment pan-
oramic radiograph showed that the roots of the teeth in
both arches were well angulated and aligned. There
were no signs of apical root resorption (Fig 15). A
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 5
Fig 11. Progress periapical radiograph, 29 months after
the start of treatment. The impacted canine was moved
and in alignment.
comparison of the pretreatment and posttreatment
cephalograms showed a normal ANB angle after treat-
ment. This decrease of the ANB angle resulted from the
anterior mandibular advancement and the decrease of
the SNA angle. This reduction in SNA angle might
reflect the distal change of Point A by palatal move-
ment of the maxillary incisors. The soft-tissue balance
improved with treatment and favorable growth (Table,
Figs 16 and 17).
The peer assessment rating index increased to 98%,
and a functional and good-looking occlusal result was
achieved. The patient was satisfied with her teeth and
Fig 12. Posttreatment facial photographs at age 16 years.
Tausche and Harzer 767
profile. The occlusion has been stable for over 48
months since the retainers were discontinued (Fig 18).
DISCUSSION
The maxillary canines are the most frequently
impacted teeth (except for the third molars). According
to Dewel,6 the maxillary canines have the longest
development period, as well as the longest and most
tortuous route from the point of formation to their final
destination in full occlusion. During their development,
the crowns of the permanent canines are intimately
related to the roots of the lateral incisors. Thus, the
absence of the maxillary lateral incisor and the varia-
tion in the root size of the tooth have been implicated as
important etiologic factors of canine impaction.2
Most clinicians agree that permanent canines are
essential for a functional occlusion, and that they play
a major role in an attractive smile. For this reason, an
orthodontists main task is to align the impacted ca-
nines. In general, horizontally impacted teeth combined
with severe root dilaceration are the most difficult to
manage and have the poorest prognoses. Some of these
teeth must be extracted.2,7-8 However, this impacted
right canine had a dilacerated root that was possible to
move and align. As a precaution, the right peg-shaped
lateral incisor was extracted only when the impacted
canine could obviously be moved.
The 36 months of active treatment might seem
longer than average, but patients with impacted maxil-
lary canines are perceived to be more difficult and
time-consuming to treat than average orthodontic pa-
tients.9 With the treatment duration, optimum dental
hygiene and perfect compliance were essential.
It is of utmost importance to minimize undesirable
768 Tausche and Harzer American Journal of Orthodontics and Dentofacial Orthopedics
May 2008

Fig 13. Intraoral views at the end of treatment. Functional and esthetically pleasing occlusal result
was achieved.

Fig 14. Posttreatment dental casts.

reactive movements of the anchor teeth and to provide
an optimum force system.2 The anchorage on the
quad-helix, transpalatal bar, and buccal-segment
wire were efficient, and it was possible to control the
intrusive effects on the adjacent teeth. To obtain an
optimal periodontal and esthetic result, the closed-
eruption technique was used as recommended in the
literature.10,11
The treatment plan included, in addition to align-
ment of the impacted right canine, extraction of the
peg-shaped lateral incisors and space closure. The
applicability of orthodontic space closure for lateral
American Journal of Orthodontics and Dentofacial Orthopedics Tausche and Harzer 769
Volume 133, Number 5

Fig 15. Final panoramic radiograph showing the roots

of the teeth in both arches are well angulated and
aligned.

Fig 17. Cephalometric superimposition.

incisors is sometimes debatable. Concerns can be re-

lated to treatment complexity and the quality of the
esthetic and the functional result. Long-term periodon-
tal and occlusal studies on congenitally missing lateral
incisors have shown that space closure with premolar
substitutions for canines can lead to an acceptable
functional relationship that is well accepted by patients.
There were no signs or symptoms of temporomandib-
ular joint dysfunction. There was no evidence to sup-
port the belief that establishing a Class I canine
relationship should be the preferred mode of treat-
Fig 16. Posttreatment cephalometric radiograph and ment.12-14
tracing. Because of the patients fragile gingival structure,
special oral hygiene instructions in the mandibular
incisal area were given to reduce the risk of dehiscence

Fig 18. Intraoral views, 3 years posttreatment.

770 Tausche and Harzer
from gingivitis.15 Furthermore, the lingual surfaces of
both maxillary canines were reduced to remove exces-
sive forces on the incisal edges of the mandibular
lateral incisors during mastication. To optimize the
esthetics (shape and color of the canine crown), we
recommended recontouring and bleaching of the max-
illary canines, but the patient refused.
CONCLUSIONS
Although the impacted right canine had a dilacer-
ated root, it was possible to move and align it. Because
of the extraction of the peg-shaped lateral incisors and
the space closure, favorable esthetics and excellent
long-term occlusal results were obtained.
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