ORIGINAL ARTICLE

Three-dimensional localization of maxillary canines with cone-beam computed tomography

Leah Walker,a Reyes Enciso,b and James Mahc Los Angeles, Calif Introduction: Precise 3-dimensional (3D) localization of impacted canines is central to their clinical management. Recently introduced dental 3D volumetric imaging systems make precise localization possible. The purpose of this study was to describe the spatial relationship of impacted canines by using images obtained with the NewTom QR-DVT 9000 (QR Srl, Verona, Italy). Methods: Unilaterally and bilaterally impacted canines (n 27) from 19 consecutive patients (15 female, 4 male) were evaluated on images taken with the NewTom QR-DVT 9000. The spatial relationships of the impacted canines relative to adjacent structures and incisor resorption were assessed with 3D visualization software. Results: Most (92.6%) of the 27 impactions were palatal. Incisor resorption adjacent to the impacted canine was present in 66.7% of the lateral incisors and 11.1% of the central incisors. Follicle size did not play a major role in inuencing impacted canine position. The alveolus was narrower at the impacted canine side compared with the erupted canine side; however, the width of the alveolus on the impacted canine side is independent of the deciduous canines. A correlation was found between the proximity of the impacted canine to the incisors and their resorption. There was no common location where eruption was arrested, and great variation in the inclination of the impacted canine was found. Conclusions: 3D volumetric imaging of impacted canines can show the following: presence or absence of the canine, size of the follicle, inclination of the long axis of the tooth, relative buccal and palatal positions, amount of the bone covering the tooth, 3D proximity and resorption of roots of adjacent teeth, condition of adjacent teeth, local anatomic considerations, and overall stage of dental development. In short, 3D imaging is clearly advantageous in the management of impacted canines. (Am J Orthod Dentofacial Orthop 2005;128:418-23)

mpacted canines are relatively common in orthodontic practice. After the third molar, the maxillary canine is the most frequently impacted tooth.1,2 The mandibular canine is much less of a concern because it is 10 times less frequently impacted.2-4 The prevalence of impacted maxillary canines is reported to be 2%,2 0.9% to 2%,4 1% to 2%,5 1.5% to 2%,6 and 1% to 3%.7 The maxillary impacted canine is more often located palatally (85%) than labially (15%).2-4 Impacted canines can also lead to the resorption of neighboring permanent teeth, particularly the lateral incisors. Various degrees of resorption on the permanent incisors have been reported, and, in 1 study, resorption was associated with approximately 48% of impacted maxillary canines.8 Additionally, resorption
From the Division of Craniofacial Sciences and Therapy, School of Dentistry, University of Southern California, Los Angeles. a Visiting researcher. b Clinical assistant professor. c Associate clinical professor. Reprint requests to: James Mah, School of Dentistry, University of Southern California, 925 West 34th St, Room 312, Los Angeles, CA 90089-0641; e-mail, jamesmah@usc.edu. Submitted, October 2003; revised and accepted, April 2004. 0889-5406/$30.00 Copyright 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.04.033

can be difcult to diagnose with conventional methods, especially if the canine is located in a direct palatal or buccal position relative to the incisor roots.9 The orthodontic-surgical management of impacted canines requires accurate diagnosis and precise location of the impacted canine and the surrounding structures.10 It is important to dene the exact position relative to neighboring structures and the inclination of the longitudinal axis of the impacted tooth. Diagnosis and treatment planning can be difcult with conventional radiographic methods, because of superimposition of structures on the lm; this often makes it difcult to distinguish details.2 Distortion and projection effects are also encountered with conventional radiographs. Recently, computed tomographic scanning (CT) has been used, because it can provide more reliable information than conventional methods.9,11 CT provides excellent tissue contrast, eliminating blurring and overlapping of adjacent teeth.2 Despite its advantages, until now, the use of CT for location of impacted teeth and assessment of resorption has been restricted because of issues related to cost, risk/benet, access, and expertise in reading the CT.12 A newly developed dental volumetric imaging device, the NewTom QR-DVT 9000 (QR Srl, Verona,

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Italy), uses cone-beam radiation to gather similar information in the working range of dental radiography. The effective absorbed radiation dose for a maxillomandibular imaging session with the NewTom QR-DVT 9000 is 50.2 Sv13; traditional medical CT results in an effective absorbed radiation dose from 124.9 to 528.4 Sv for a mandibular examination and 17.6 to 656.9 Sv for a maxillary examination, depending on the volume of the arch imaged and the operational settings of the CT.13 The effective dose with a panoramic examination is 2.9 to 9.6 Sv14 and that for a fullmouth series is 33 to 84 Sv14 or 14 to 100 SV,15 depending on variables such as lm speed, technician, kVp, and collimation. The aim of this study was to quantify the spatial relationship of impacted maxillary canines by using 3-dimensional (3D) volumetric imaging. The following factors were analyzed: proximity to adjacent structures, resorption of incisors, alveolar width, and follicle size. Results for 19 consecutive subjects referred for imaging with a diagnosis of impacted canines are presented here.
MATERIAL AND METHODS

75 seconds. The device acquires 360 images at 1 intervals, with a resolution of 512 512 pixels and 8 bits per pixel (256 greyscale). The reconstruction matrix voxel is 0.25 0.25 0.3 mm. Software from the manufacturer allows for secondary reconstructions to be produced that show many viewpoints of the structures of interest. These secondary reconstructions include transaxial, panoramic, and 3D views. Measurements were made on these views (distances and angles). Imaging data were analyzed with software from the manufacturer. This study focused on the following: 1. Type of impaction. 2. Resorption of incisors. 3. Proximity of the impacted canine to the lateral and central incisors. This was measured as the shortest distance between the impacted canine and the incisor. Contact was dened as proximity of less than 0.5 mm. 4. Follicle size measured at the widest area from the crown to the periphery of the follicle (Fig 1). If the dimension from the crown to the periphery of the follicle was less than 2 mm, it was considered to be within normal limits, and if it was greater than 2 mm, it was considered to be an enlarged follicle. 5. Existence of deciduous canines. 6. Alveolar width in the area of the canine (both impacted and normally erupted). This was measured at the level of the cervical margin of the adjacent teeth of both left and right sides. 7. Location. This was determined from 3 views: coronal or frontal (Fig 2), sagittal (Fig 3), and axial or horizontal (Fig 4). Distances and angles were measured with the NewTom software on these views. For assessment of location, reference lines were created that consisted of a horizontal occlusal plane line and a vertical line bisecting the midline of the jaws. All distances were measured perpendicularly from the reference lines to the cusp tip of the tooth. The angles measured were the angles formed by the line bisecting the long axis of the tooth and the reference line. From the coronal view, the following measurements were taken: distance from cusp tip of the impacted canine to the occlusal plane, distance from cusp tip of the impacted canine to the midline, angle of the impacted canine to the occlusal plane, and angle of the impacted canine to the midline. From the sagittal view, the following measurements were taken: distance from the cusp tip of the impacted canine to the occlusal plane, distance from the cusp tip of the impacted canine to the frontal plane, angle of the impacted canine to the occlusal plane, angle of the lateral incisor to the

Cone beam CT images were collected from 19 consecutive patients (15 female, 4 male) who were referred for localization of either unilateral or bilateral impacted or ectopically erupting canines (images courtesy of Dr David Hatcher). These clinical situations are considered here as a single group when describing the localization; a diagnosis was not made because complete patient data were not available. A total of 27 impacted or ectopically erupted maxillary canines were studied, including 16 bilateral impactions, 5 left unilateral impactions, and 6 right unilateral impactions. The patients ages ranged from 8 to 20 years (average, 13.3; SD, 2.98). The age of 1 patient with a unilateral impaction was unavailable. In 48.1% of the cases, the deciduous canine was still present. Of these, 33.3% were overretained. Overretention was determined by the patients chronological age and the average age in which the deciduous canine exfoliates (11 years 9 months for maxillary canines16). In the sample, 61.1% of the patients had adult dentitions, and 38.9% were still in the mixed-dentition stage (not including the patient whose age was missing). Of the mixed-dentition patients, the impacted canine was evaluated before eruption of either the rst or the second premolar. The NewTom QR-DVT 9000 is a dental maxillofacial volumetric imaging system with a reconstruction volume of 110 150 mm and an imaging time of about

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Fig 1. Follicles were measured in millimeters from crown to periphery of follicle (axial view).

Fig 3. Angle of impacted canine to occlusal plane (19.5) and distance of cusp tip from occlusal plane (24.2 mm).

than 1 or 2 mm (depending on the factor being measured) were measured to the nearest half millimeter. All measurements were made twice, and the mean was reported.
RESULTS

Fig 2. Distances of cusp tip of impacted canine to midline and occlusal plane. Tooth was visible only from incisal view.

occlusal plane, and angle of the central incisor to the occlusal plane. From the axial view, the following measurements were taken: distance from the cusp tip of the impacted canine to the midline and angle of the impacted canine to the midline. In this study, angles greater than 5 were reported (angles less than 5 were too indistinct to allow for more accurate measurement), and distances greater

Most of the patients with impacted canines in this study (78.9%) were female. There was no signicant difference between left and right impactions. Most of the maxillary impactions were located palatally (92.6%), and only 7.4% were located buccally. One buccally impacted canine was between the premolars, with resorption of the rst premolar. Of the 27 cases of impacted maxillary canines, 21 incisors were resorbed, including 18 lateral incisors (66.7% of 27 cases) and 3 central incisors (11.1% of 27 cases) (Table I). All central incisor resorption cases also had lateral resorption. In 1 subject, both lateral incisors were missing. In 1 impaction case, the resorption was on the rst premolar. In all bilateral cases, which had lateral resorption, both laterals were resorbed. In the only bilateral case in which the central incisor was resorbed, the resorption was unilateral. The impacted canine in 63.0% of the 27 cases was in contact (distance less than 0.5 mm) with the lateral incisor, and, in 18.5% of the 27 cases, the impacted canine was in contact with the central incisor (Table II). The average distances of the impacted canine to the

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Table I.

Incisor resorption associated with 27 impacted

Resorption 18/27 (66.7%) 3/27 (11.1%) No resorption* 9/27 (33.3%) 24/27 (88.9%)

canines
Incisors Lateral Central

*Includes 2 missing lateral cases.

Table II.

Proximity between 27 impacted canines and adjacent incisors

Incisors Contact 17/27 (63.0%) 5/27 (18.5%) No contact* 10/27 (37.0%) 22/27 (81.5%)

Lateral Central

*Includes 2 missing lateral cases.

Fig 4. A, Angle of impacted canine to midline (4.6) in axial view (does not accurately depict tip of cusp). B, Distance from cusp tip to midline (16.8 mm).

average widths of the alveolus were 10.6 1.04 mm at the erupted canine cervical margin and 8.0 2.67 mm on the affected side (Table III). The distances measured from the impacted canine to the midline varied to some extent in the coronal and axial views. Averages for the distance of the cusp tip of the impacted canine to the midline were 10.8 4.17 mm and 10.6 3.96 mm in the axial and coronal views, respectively. The distance from the cusp tip of the impacted canine to the frontal plane averaged 7.9 3.18 mm in the sagittal view. The greatest variation was found from the cusp tip of the impacted canine to the occlusal plane in the coronal and sagittal views.
DISCUSSION

lateral incisor and central incisor were 1.4 2.15 mm (Fig 5) and 3.5 2.90 mm (Fig 6), respectively. By using the measurements shown in Figure 1, approximately half of the impacted canine follicles examined were within normal limits (53.8%). The remaining cases (46.2%) were considered enlarged ( 2 mm). Follicle size varied from less than 2 to 8.7 mm, with an average of 3.6 mm. In one case, the follicle was not detected. Of the 27 impacted cases evaluated, 13 had deciduous canines (48.1%) and 14 (51.9%) did not. From an axial view, the width of the alveolus at the erupted canine cervical margin was measured and compared with the width of the alveolus of the affected side at the level of the cervical margin of the adjacent teeth for the unilateral impacted canine cases. In all cases but 1, there was a clinical decrease in the width of the alveolus at the affected side compared with the width of the alveolus of the erupted canine. The

Incisor resorption adjacent to the impacted canine was present in 66.7% of the laterals and 11.1% of the centrals (Table I). The percentage of resorbed centrals is comparable with previous reports using CT images in which 9% of the centrals were resorbed.8 In our study, only 1 case involved the resorption of the rst premolar, suggesting that resorption of the rst premolar is unusual. This study supports previous claims that resorption on maxillary incisors after ectopic eruption of the maxillary canines is a relatively common phenomenon and must be considered in all patients with seriously diverging eruption of the maxillary canines.8 There was a correlation between the proximity of the impacted canine to the lateral incisor and the central incisor, and the resorption of the incisors caused by the impacted canine. The impacted canine was in contact (shortest distance less than 0.5 mm) with the lateral incisor in 63.0% of the cases and with the central incisor in 18.5% of the cases (Table II). This information is supported by

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Fig 5. Proximity of impacted canine to lateral incisor.

Fig 6. Proximity of impacted canine to central incisor.

the results of a previous study in which 93% of the impacted canines were in contact with roots of the adjacent lateral incisor and 19% with the central incisor.8 Resorption was present when the impacted canine was within 0.5 mm of the lateral incisor, and, in 1 exceptional case, resorption occurred with proximity of 2.3 mm (Fig 5). Two of the 3 resorbed central incisors had the impacted canine within 0.5 mm of the central incisor (Fig 6). However, in 3 other cases, proximity of the impacted canine to the central incisor was less than 0.5 mm, with no resorption. The exceptions for both the central and lateral incisors were in the same patient, and an enlarged follicle surrounded the impacted canine. This correlation supports previous claims that there must be close contact between the canine and the lateral incisor rather than mediation of resorption by swelling of the dental follicle.4 The widths of the dental follicle of the impacted canines varied greatly. There was no correlation between follicle size and impaction of the canine. This

result suggests that follicle size does not play a major role in inuencing impacted canine position. There was no signicant correlation between presence of deciduous canine and width of the alveolus on the impacted canine side. This suggests that alveolus width is independent of the deciduous canines. Measurements made on different views showed that the distance from the cusp tip of the impacted canine to the midline of the jaws is relatively constant, whereas the distance from the cusp tip of the impacted canine to the occlusal plane varies widely. This indicates that impactions vary greatly, and there is no common mode of impaction. There is considerable variation to the inclination of the impacted canine; some are horizontally impacted, and others are vertically impacted with variations in between. The prevalence of maxillary canine impactions seems to vary within a range of 0.9% to 3.0%,2,4-7 with a higher prevalence in females.17-20 In our study sample, we had more females than males. One can only

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Width of alveolus measured (in mm) at erupted canine cervical margin and on affected side at level of cervical margin of adjacent teeth. Missing alveolar measurements correspond to bilateral impactions
Case # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Average SD Variance At erupted canine cervical margin 10.50 10.75 9.75 10.0 9.85 13.25 10.20 10.30 11.65 10.20 9.85 10.6 1.04 1.08 On affected side 3.55 6.45 7.95 6.15 8.10 14.20 8.60 9.65 9.45 6.80 7.20 8.0 2.67 7.13

Table III.

REFERENCES 1. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420-5. 2. Elefteriadis JN, Athanasiou AE. Evaluation of impacted canines by means of computerized tomography. Int J Adult Orthod Orthognath Surg 1996;11:257-64. 3. Shapira Y, Kuftinec MM. Early diagnosis and interception of potential maxillary canine impaction. J Am Dent Assoc 1998; 129:1450-4. 4. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopic eruption of the canines. Am J Orthod Dentofacial Orthop 1988;94:503-13. 5. Ericson S, Kurol J. Incisor resorption caused by maxillary cuspidsa radiographic study. Angle Orthod 1987;57:332-46. 6. Fox NA, Fletcher GA, Horner K. Localizing maxillary canines using panoramic tomography. Br Dent J 1995;179:416-20. 7. Stewart JA, Heo G, Glover KE, Williamson PC, Lam EW, Major PW. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop 2001;119:216-25. 8. Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000;70:415-23. 9. Ericson S, Kurol J. CT diagnosis of ectopically erupting maxillary caninesa case report. Eur J Orthod 1988;10:115-21. 10. Preda L, La Fianza A, Di Maggio EM, Dore R, Schino MR, Campani R, et al. The use of spiral computed tomography in the localization of impacted maxillary canines. Dentomaxillofacial Radiol 1997;26:236-41. 11. Bodner L, Bar-Ziv J, Becker A. Image accuracy of plain lm radiography and computerized tomography in assessing morphological abnormality of impacted teeth. Am J Orthod Dentofacial Orthop 2001;120:623-8. 12. Schmuth GPF, Freisfeld M, Koster O, Schuller H. The application of computerized tomography (CT) in cases of impacted maxillary canines. Eur J Orthod 1992;14:296-301. 13. Mah J, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental CT. Oral Surg Oral Med Oral Pathol 2003;96:508-13. 14. Danforth RA, Clark DE. Effective dose from radiation absorbed during a panoramic examination with a new generation machine. Oral Surg Oral Med Oral Pathol 2000;89:236-43. 15. Gibbs SJ. Effective dose equivalent and effective dose: comparison for common projections in oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol 2000;90:538-45. 16. Berkovitz B, Holland G, Moxham B. Color atlas and textbook of oral anatomy, histology and embryology. London: Mosby Year Book, 1992:288-9. 17. Ericson S, Bjerklin K. The dental follicle in normally and ectopically erupting maxillary canines: a computed tomography study. Angle Orthod 2001;71:333-42. 18. Dachi SF, Howell FV. A survey of 3874 routine full-mouth radiographs II. A study of impacted teeth. Oral Surg Oral Med Oral Pathol 1961;14:1165-9. 19. Becker A, Smith P, Behar R. The incidence of anomalous lateral incisors in relation to palatally displaced cuspids. Angle Orthod 1981;51:24-9. 20. Oliver RG, Mannion JE, Robinson JM. Morphology of maxillary lateral incisor in cases of unilateral impaction of maxillary canine. Br J Orthod 1989;16:9-16.

speculate on the possible reasons for this nding. It could be related to differences in overall craniofacial growth and development between the sexes or genetics, or simply because more girls and women seek orthodontic treatment. This study also showed that palatal maxillary impactions (92.6%) are more common than buccal impactions (7.4%); this agrees with previous reports.2-4,20
CONCLUSIONS

Our ndings demonstrate that the 3D volumetric imaging provides invaluable information about impacted canines to better understand and treat these cases surgically and orthodontically.