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ARTICLE 2

EARLY DIAGNOSIS AND INTERCEPTION

OF POTENTIAL MAXILLARY CANINE IMPACTION
YEHOSHUA SHAPIRA, D.M.D.; MLADEN M. KUFTINEC, D.STOM.,
D.M.D., SC.D.

A B S T R A C T Maxillary canine impaction is a dental anomaly often encountered

The authors present clinical and
radiographic measures for the
early detection of potential max-
illary canine impaction. Inter-
cepting the impaction process
by timely removal of the primary
canines, as demonstrated in sev-
eral representative cases, allows
the permanent canines to erupt
normally and, thus, prevents
in orthodontic practice. After the third molar, the maxillary canine
is the most frequently impacted tooth.1 The incidence of maxillary
canine impaction has been reported in approximately 2 percent of
patients seeking orthodontic treatment.2,3 Maxillary canines are 10
times more commonly impacted than their mandibular counter-
parts.4,5 Palatal impaction of canines is reported to be much more
prevalent than labial impaction (85 percent and 15 percent, respec-
tively),2,6,7 and unilateral impaction is much more common than bi-
lateral.8 Similarly, maxillary canine impaction is more frequent in
girls and women and is commonly associated with peg-shaped or
missing lateral incisors.9
This article focuses attention on maxillary impacted canines with
specific emphasis on early detection and possible prevention.

their potential impaction. EARLY DETECTION: THE KEY

Early detection of the maxillary canine’s possible impaction can be

made in patients as young as 9 to 10 years of age, though wide vari-
ation in eruption time has been reported.10 This is based on a combi-
nation of careful clinical and complete radiographic examinations.
Clinically, digital palpation of the buccal sulcus above the primary
canine root, which can reveal the position of the maxillary perma-
nent canine even in a 9- or 10-year-old patient, has been recom-
mended as a tool for early diagnosis.11-13
Provided that a buccal bulge can be palpated in the primary ca-
nine apical region, the permanent canine is likely in a favorable
eruption position.11,13 When the canine bulge cannot be identified by
digital palpation, eruption disturbance of the permanent canine
should be suspected and confirmed radiographically at the age of 9
or 10 years,14,15 or at a slightly later age (11 years or so) as recom-
mended by other authors.16-18
During the clinical examination, the permanent lateral incisors
should be carefully checked. Their abnormal position or angulation
could indicate a mesially deflected canine, which has the potential
to become impacted.19 Severely distally tipped crowns of lateral in-
cisors might be pressured by the crown of the mesially displaced ca-

1450 JADA, Vol. 129, October 1998

Copyright ©1998-2001 American Dental Association. All rights reserved.
 CLINICAL PRACTICE

R L

Figure 1. Maxillary right and left lateral incisors are

labially tipped owing to the pressure from the
crowns of the mesially displaced canines exerted on
the labial side of the lateral incisors’ roots in an 11-
year-old girl. The panoramic radiograph shows the
enlarged follicle of the unerupted permanent canines
with no evidence of primary canine root resorption
and the presence of a mesiodence (arrow).

nine against the distal aspect of moved too

the lateral incisor root.11 A labi-
ally inclined lateral incisor
could be a result of a similarly
displaced canine lying on the
labial aspect of the lateral in-
cisor root.11 This situation is
presented in the case of an 11-
year-old girl whose permanent
canines were palpated high at
the region of the lateral incisor
roots but in whom there was no
evidence of primary canine root
resorption (Figure 1). After re-
moval of the primary canines,
the left permanent canine
erupted uneventfully, while the
right one—being labially im-
pacted above the lateral incisor
root—was surgically exposed
and orthodontically brought
into the arch.
A palatally ectopic canine
can cause the lateral incisor
crown to incline distally and ro-
tate, as demonstrated in the
case of a 13-year-old boy whose
retained primary canine showed
no root resorption and in whom
the canine bulge could not be
palpated (Figure 2). The re-
tained primary canine was re-
late, as the
permanent ca-
nine had al- B
ready become Figure 2. Distally tipped and rotated maxillary left lat-
impacted. The eral incisor caused by a palatally ectopic permanent
clinician wait- canine in a 13-year-old boy. A. Panoramic view show-
ing enlarged follicle around the unerupted canine
ed five addi- with no evidence of resorption of the primary canine.
tional months B. Five months after the removal of the primary ca-
nine, the lateral incisor is further tipped distally, en-
in the hope larging the space with the central incisor.
that the per-
manent canine would erupt on the primary canine root. This
its own, but in that time the lat- should be done bimanually,
eral incisors tipped even further with index fingers of both hands
distally. At that stage, it was palpating simultaneously in
necessary to surgically expose both the buccal and palatal
the canine and direct it into the sides above the primary ca-
arch (Figure 2). Excessive or un- nine.13 Retention of the primary
usual mobility of the maxillary canine beyond the age of 12 to
permanent lateral incisor could 13 years, with no signs of mobil-
be a result of root resorption ity and no labial canine bulge,
caused by a displaced canine. It could indicate impaction of the
should be carefully examined permanent canine, which
radiographically20 and, if neces- should be confirmed radio-
sary, with computed tomogra- graphically.
phy, or CT.21-24 Radiography. Among the
diagnostic procedures for de-
DETECTING IMPACTED
MAXILLARY TEETH
tecting potentially impacted ca-
nines, radiographic examina-
Palpation. Normally, a maxil- tion is essential in locating and
lary canine can be palpated determining the position of the
high in the labial sulcus above tooth. To determine whether

JADA, Vol. 129, October 1998 1451

Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE
tioned buccal-
ly. Taking a
vertex occlusal
view radio-
graph with the
X-ray beam di-
rected along
the long axis
of the central
incisors is an
additional di-
agnostic aid to
A determine and
confirm the lo-
cation of the
canine.
Panoramic
radiography.
The routine
panoramic ra-
diograph of
the mixed den-
tition taken in
the orthodon-
tic practice
also can be
B useful in de-
Figure 3. A. Panoramic radiograph of a 10-year-old tecting a posi-
girl. Note the enlarged follicles around the canine tion of the
crowns. No root resorption of the primary canines
can be detected. B. Panoramic radiograph taken 18
malposed
months after removal of the primary canines show- unerupted ca-
ing the normally erupting permanent canines. nine. When
the canine
the canine is positioned palatal- cusp tip is located mesial to the
ly or buccally, the clinician can long axis of the erupted lateral
use Clark’s rule, termed the incisor root, the canine can be-
“image shift principle”: “same come palatally impacted.25
lingual, opposite buccal.” Two When the canine cusp tip over-
periapical radiographs are lays the distal half of the lateral
taken of the canine in the same incisor root, the canine only oc-
horizontal plane with the radio- casionally becomes palatally im-
graphic cone at different angu- pacted25 (Figure 3). The
lations (the second film is taken panoramic radiograph may,
at a more distal angle from the however, show some tooth dis-
first one). The movement of the tortion that should be taken
canine on the films is assessed into consideration and, there-
relative to a nearby object, such fore, should not be used as the
as the lateral incisor. When the single source of diagnostic infor-
canine moves in the same direc- mation. Radiographs from addi-
tion as the cone, it is located lin- tional aspects, such as periapi-
gually (palatally). When the ca- cal or vertex occlusal, are
nine moves in the opposite required to confirm the finding
direction of the cone, it is posi- from the panoramic radiograph.
1452 JADA, Vol. 129, October 1998
Copyright ©1998-2001 American Dental Association. All rights reserved.
When frontal radiographs
(such as postero-anterior
cephalograms) are used for as-
sessment of its pre-eruptive de-
velopment, the canine should be
inclined slightly mesially with
the crown below the level of the
apexes of the lateral incisors
and below the lateral border of
the nasal cavity. The canine
root should superpose or lie dis-
tal to the lateral border of the
nasal cavity.26 If the canine is
mesially tipped in the frontal
radiograph with its crown medi-
al to the lateral border of the
nasal cavity and there is no evi-
dence of primary canine root re-
sorption, an impending im-
paction of the displaced
maxillary canine should be sus-
pected.
CT. An expensive, nonrou-
tine method for the three-di-
mensional diagnosis of an ec-
topic maxillary canine, using
CT, has been suggested, espe-
cially when its root ankylosis or
the lateral incisor root resorp-
tion is suspected. The trans-
verse orientation of the image
can detect the labio-lingual po-
sition of the impacted canine
and the extent and exact loca-
tion of the lateral incisor root
resorption, which could not be
otherwise detected by other ra-
diographic techniques.23,24 A fre-
quency of 12.5 percent for the
ectopically erupting maxillary
canines causing some degree of
incisor root resorption has been
reported, significantly more
often in girls than in boys.20,22
THE INTERCEPTIVE
PROCEDURE
The best time to begin assessing
a patient for potential maxillary
canine impaction is the age of 9
to 10 years, when the canine be-
gins its long intrabony move-
ment toward its usual position

in the dental arch, and the pri-
mary canine root starts to re-
sorb. When the permanent ca-
nine is mesially displaced and
does not follow the guidance of
the lateral incisor root (usually
identified radiographically), the
lateral incisor is distally in-
clined and rotated. The bulge of
the erupting canine cannot be
palpated, and overretention of
the primary canine often occurs,
along with the impaction of the
permanent canine.
Prevention of this condition
is obviously the ideal form of
treatment and provides the best
long-term results. This is
demonstrated in the case of a
10-year-old girl with bilateral
maxillary canines mesially in-
clined, pressing the roots of the
lateral incisors, with the result
of their distal tipping. The pri-
mary canines show no sign of
resorption, while an enlarged
follicle is evident around the
crowns of the permanent ca-
nines (Figure 3). A failure of the
primary canine roots to resorb
creates a potential mechanical
obstacle for the normal eruption
of the permanent canine.
Occasion-ally, resorption of the
primary canine root is arrested,
which prevents the normal
eruption of the permanent ca-
nine.
Reasonable attempts should
be made to improve the local
conditions for the displaced ca-
nine to erupt into its proper po-
sition in the arch. Therefore,
the recommended interceptive
procedure includes timely ex-
traction of the primary canines
to prevent the possible im-
paction of the permanent ca-
nines. The removal of the pri-
mary canines usually allows the
permanent canines to become
upright and erupt into their
proper positions in the arch,
Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE
providing
enough space
is avail-
able.12,26-28
A follow-up
panoramic ra-
diograph,
taken 18
months after
the removal
of the prima- A
ry canines,
shows the two permanent ca-
nines normally erupting into
the arch, with no orthodontic
intervention (Figure 3).
A similar position of the
maxillary permanent canines
was found in this patient’s 11-
year-old brother, for whom a
similar preventive procedure
was undertaken. The perma-
A failure of the
primary canine roots
to resorb creates a
potential mechanical
B
obstacle for the
normal eruption of
Figure 4. A. Panoramic view of an
11-year-old girl showing a follicu-
the permanent lar cyst pressing the maxillary left
canine upward and horizontally.
canine. Root resorption of the maxillary
left and right primary canines has
not started yet. B. Periapical ra-
diograph taken one year after the
removal of the primary canines,
nent canines erupted into the showing the uprighting and erup-
arch uneventfully. We should tion of the permanent canine.
note that it is possible that this
phenomenon might be genetic. for orthodontic treatment. This
We have previously discussed canine, which was deflected into
issues of familial and genetic a semihorizontal position, could
aspects of impaction.8 We tend become impacted, as the prima-
to support the former, but have ry canines on both sides showed
some reservations about the lat- no root resorption (Figure 4).
ter, which should await discov- Interceptive measures consisted
ery of specifically altered loci of removal of the two primary
within the human genome. canines, together with a follow-
The development of a follicu- up observation. The periapical
lar cyst is demonstrated around radiographs taken one and two
the crown of the maxillary left years later show the left canine
permanent canine in an 11- uprighting and erupting into
year-old girl who was referred the arch. The right canine later
JADA, Vol. 129, October 1998 1453
CLINICAL PRACTICE
erupted uneventfully (Figure 4). nated by simple, timely inter-
ceptive procedures that reduce
CONCLUSION
the likelihood of canine im-
Early diagnosis and detection of paction and prevent possible in-
a potentially impacted maxil- cisor root resorption. ■
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