Interceptive Orthodontics Facilitating Permanent Maxillary Canine Eruption

Early Diagnosis, Interception and Treatment Strategies for canine impaction and displacement.

Profile. MDS in Orthodontics from Meenakshi Ammal Dental college, Chennai, India, completed in 2004. Practiced in India, Saudi Arabia and working in UAE since 2015. Publications Classification System for Self-ligating Brackets. Chapter Published: December 2023, Intechopen textbook. Interproximal Reduction Facilitating Orthodontic Teeth Extraction. Article Published: July 05, 2023, Cureus Journal of Medical Science, Part of Springer Nature. Certifications Global Online Fellowship in Temporomandibular Joint, Related Disorders and the Management Strategies (FTMJF) (Provisional certificate). Pursuing Fellowship in TMD / TMJ Orofacial Pain and Dental Sleep Medicine, Roseman University. Memberships Peer Reviewer for the Cureus Journal of Medical Science. Member at Indian Orthodontic Society, Member of World Federation of Orthodontists, Member of American Association of Orthodontists. Member of International Orthodontics Foundation, Member of the Emirates Orthodontic Society. Member of Indian Dental Association, Member of Saudi Orthodontic Society..

Introduction Understanding Maxillary Canines Etiology of Ectopic Eruption & Impaction Diagnosis Management by Interceptive orthodontics Conclusion.

The American Association of Orthodontists (AAO) recommends that your child get a check-up with an orthodontist at the first recognition of the existence of an orthodontic problem, but no later than age 7..

Early diagnosis and detection of a potentially impacted maxillary canine and timely interceptive treatment reduces the need for complicated orthodontic treatment, necessitating the practitioners be equipped to address it..

Eruption disturbances can be associated with any erupting tooth although most appear to be associated with the First permanent molars, Maxillary permanent canines, Maxillary permanent central incisors and Second premolars. Kurol J. Early treatment of tooth-eruption disturbances. Am Orthod Dentofacial Orthop 2002;121:588–591..

American Association of Orthodontics (1969) “That phase of science & art of orthodontics employed to recognize & eliminate potential irregularities & malpositions of the developing dentofacial complex”. Richardson (1982) “Prompt intervention addressing the unfavorable features of a developing occlusion that may make the difference between achieving a satisfactory result by simple intervention, thus reducing the overall treatment time and providing better stability, functional and aesthetic results”..

Lindauer et al. defined a canine as being impacted if it was unerupted after complete root development or if the contralateral tooth was erupted for at least 6 months with complete root formation. Baccetti et al. that beyond the stage CS5 of cervical vertebral maturation, which occurs on average 1 year after the end of the adolescent growth spurt, displaced canines can be defined as impacted canines..

Andreasson JO An Ectopic tooth is displaced from its normal position whereas an Impacted tooth is ‘blocked’ from erupting into its usual occlusal location in the dental arch by other teeth, bone or fibrous tissue. Kuftinec & Shapira Impaction is a “condition in which a tooth is embedded in the alveolus and its spontaneous eruption is prevented by a local mechanical obstruction or position of adjacent teeth”..

An impacted canine is defined as “a tooth retained in the maxillary or mandibular arch beyond the date of eruption, surrounded by its pericoronal sac and has no contact with the oral cavity”. Delsol L, Orti V, Chouvin M, Canal P. Tooth impaction can be defined as the infraosseous position of the tooth after the expected time of eruption, whereas displacement is the anomalous infraosseous position of the canine before the expected time of eruption. S M Power, M B Short.

[image]. Canines are the corner teeth & cornerstone of the dental arch, often known as “fangs” or “eye” teeth. Critical for aesthetics, function and stability..

Longest tooth and longest root, travels almost 22 mm during the time of eruption. Important for Canine guidance, aesthetic importance Remains high in the maxilla above the root of the lateral incisor until the crown is calcified. Maxillary canines often erupt above the gum line..

First evidence of calcification 4 to 5 months of age. Enamel formation is complete by 6 to 7 years of age. Erupt at around 11 to 12 years of age. Root formation is complete by 13 to 15 years of age..

The maxillary canine is 2nd to the mandibular 3rd molar in its frequency of impaction, Bishara, 1992; Cooke & Wang, 2006; Ericson & Kurol, 1986., prevalence 0.9%-3.3%. Prevalence in Caucasians 1-3.5%. Ectopic canines occur palatally 85% with a much greater frequency than they do buccally 15%. Shapira et.al, Sambataro Bilateral impaction 8%. Peck & Peck left side is affected more than the right.

The maxillary impacted canine is more often located palatally (85%) than labially (15%) (Bishara, 1992; Cooke & Wang, 2006; Ericson & Kurol, 1986; Ferguson, 1990; Grover & Lorton, 1985; Warford, Grandhi, & Tira, 2003). Root dilaceration is reported to be present in up to 59.5% of the cases (da Silva Santos et al., 2014). Twice as common in females compared to males 2:1, (Dachi and Howell). The prevalence of the mandibular canine impaction is lower (0.35%) than that of the impacted maxillary canine.

Etiology of Ectopic Eruption and Impaction.

B. Holly Broadbent; Ontogenic Development of Occlusion. Angle Orthodontics, 1941.

Systemic causes: Thyroid gland alterations, hypovitaminosis A and D, irradiation, cleft lip and palate, and craniofacial syndromes. Bishara, SE, febrile diseases, other endocrine deficiencies, malnutrition, anemia, and rickets. Local causes: Early trauma, odontomas, dentigerous cysts enlarged dental follicles, eruption pathway obstructions, apical lesions, altered or missing maxillary lateral incisors, ankylosis, early loss of primary canines, and maxillary dimensional deficiencies. Becker, A ∙ Zogakis, I ∙ Luchian, I, prolonged retention of the deciduous canine. Genetic causes: Heredity, malposed tooth germ, presence of an alveolar cleft.

Rotation of tooth buds, disturbances in tooth eruption sequence, lack of space, premature root closure, canine eruption into cleft areas, and localized pathological lesions. Hypodontia, agenesis, aplasia and supernumerary teeth (Peck et al., 1994, Becker et al., 1995). Transverse maxillary deficiency, Schindel R, Duffy S., McConnell TL, Hoffman DL, Forbes DP, Janzen EK, Weintraub NH..

Genetically programmed to develop between the permanent lateral incisor and the first premolar teeth in the region of the infra-orbital foramen by homeobox genes. Genetic control of the eruption is modified by local ‘risk’ factors producing several opportunities for permanent maxillary canines to become ectopic. lateral incisor root guides, peg-shaped permanent lateral incisors & developmentally absent permanent lateral incisors have been associated with a greater incidence of palatal canine impaction. McIntyre, Grant. (2008). The maxillary canine : Part 1: Diagnosis, localisation, and interceptive treatment. Orthodontic Update. 1. 7-15. 10.12968/ortu.2008.1.1.7..

1. The Guidance Theory. (Becker A, Smith P, Behar R.) The crown of the upper canine is guided into position within the arch by the root of the lateral incisor. 2. The Genetic Theory. (Peck S & Peck L) The developmental position of the upper canine is thought to be under genetic control and ectopia associated with the presence of other dental anomalies, i.e., peg or missing lateral incisors, which are also considered to be under genetic control..

The aetiology of the palatal canine ectopia likely to be polygenic & multifactorial. Occurring more often among family members and may be linked with absent or anomalous lateral incisors, an absence of crowding, and late developing dentitions. Zilberman Y, Cohen, Becker A.; Brin I, Becker A, Shalhav M.; Chausu S, Sharabi S, Becker A..

Dental Anomalies Associated With palatally displaced canines (PDCs) Small, peg-shaped, or agenesis of lateral incisors, 2nd premolar agenesis, infraocclusion of primary molars, generalized maxillary crown size reductions, enamel hypoplasia, and third molar agenesis. Peck et al reported a 40% concurrence of 3rd molar agenesis with PDCs Sacerdoti & Baccetti demonstrated 3rd molar agenesis occurring in 36.6% Dental anomalies that are not significantly associated with PDCs Supernumerary teeth Ectopic eruption of first permanent molars.

Al-Nimri K and Gharaibeh reported that palatal canine impaction occurred most frequently in subjects with a Class II, Division II malocclusion (44%). Ludicke et al., evaluating the panoramic radiographs, cephalograms and pretreatment study models of 199 patients (12.7 yrs.) with impacted canines, found that 45% of the patients had Class II, Division II malocclusion. Sambataro et al., the closer the canine crown is to the mid-sagittal line and the larger the posterior part of hemi-maxilla in the anterior-posterior analysis the higher the probability of eruption disturbance..

Sacerdoti R & Baccetti 60% of the patients with PDCs have a low angle vertical growth pattern. Stellzig A et al. 80% of patients with impacted canines have horizontal facial growth pattern. Mc Connell et al., implicated a transverse maxillary deficiency in the anterior portion of the dental arch as a local cause for palatal canine displacement. Athanasiou et al.; individuals with palatally impacted canines have a straighter or less convex skeletal profile, shorter anterior facial height with a more horizontal mandibular plane, and a sagittally extended anterior region of the maxilla, corresponding to the pre-maxillary area..

Labial or lingual mal-positioning tooth. Migration of the neighboring teeth and shortening of the dental arch. Internal resorption. Dentigerous cyst formation. External root resorption of the impacted tooth, as well as the neighboring teeth. Canine tooth ankylosis. Infection particularly with partial erupt. Referred pain and combinations of the above sequelae. Shafer WG, Hine MK, Levy BM, editors. A textbook of oral pathology. 2nd ed. Philadelphia: WB Saunders; 1963. pp. 2–75..

Absence of maxillary dento-alveolar symmetry (where the condition is unilateral); Limited deciduous canine prognosis often with poor aesthetics; Absence of canine protected occlusion; Obstruction to movement of nearby teeth; Flattened nasolabial fold due to the absence of the canine eminence; Managing the maxillary canine: 1. diagnosis, localization and interceptive treatment, Grant T McIntyre, Orthodontic Update 2008 1:1, 7-15, DOI: 10.12968/ortu.2008.1.1.7.

Diagnosis.

Failure to diagnose and treat impacted maxillary canines early may increase the risk of unfavorable sequelae, such as resorption of the lateral incisor root, cyst formation, and internal resorption of the impacted tooth. Alzain I, Batwa W, Kamrani A, Bawazir R. Early assessment of ectopic maxillary canine. EC Dent Sci 2017 May;10(5): 125-131. Brown LH, Berkman S, Cohen D, Kaplan AL, Rosenberg M. A radiological study of the frequency and distribution of impacted teeth. J Dent Assoc S Afr 1982 Sep;37(9):627-630. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopic eruption of the canines. A clinical and radiographic analysis of predisposing factors. Am J Orthod Dentofacial Orthop 1988 Dec;94(6):503-513..

Visual Inspection , Palpation Delayed eruption of the permanent canine, over retention of the primary canine, absence of a labial bulge, presence of a palatal bulge. Distal crown tipping of the lateral incisor. Ericson and Kurol suggested that absence of the “canine bulge” when the child is around 11 years of age is not an indication of canine impaction. However, they suggested palpation of the buccal surface of the alveolar process distal to the lateral incisor to help determine the position of the maxillary canine before its emergence. If a labial bulge is absent in a 9 or 10 year old patient, a radiograph obtained to confirm the diagnosis..

Series of concomitant tooth disturbances such as small size of upper lateral incisors, enamel hypoplasia, aplasia of second premolars, and infraocclusion of primary molars. Arch length deficiency is believed to be the most common cause of labially impacted canines. Becker reported an increase of 2.4 times in the incidence of palatally impacted canines adjacent to missing lateral incisors Ectopic maxillary canines were highly associated with ectopic mandibular canines; Waeil Batwa, Ibtesam Alzain.

Buccally displaced canines tended to have maxillary transverse constriction and variation in palatal vault morphology. Manuela et.al. Young people with a narrower than average upper jaw are more likely to have a PDC, hence the idea of creating more space for the unerupted tooth (Schindel 2007). The shape of the maxillary arch was narrower and shorter in the displaced maxillary canines group compared with the control group. Cacciatore G, Poletti L, Sforza C. Progress in Orthodontics, 2018.

Clinical Evaluation Bishara SE. AJO 1992 suggested that the following clinical signs might be indicative of canine impaction: Delayed eruption of the permanent canine or prolonged retention of the deciduous canine beyond 14-15 years of age, Absence of a normal labial canine bulge, Presence of a palatal bulge, Delayed eruption, distal tipping, or migration (splaying) of the lateral incisor..

Intra-Oral Intraoral Periapical Radiograph (IOPA) Occlusal Radiograph The intra-oral Ultrasound (io-US) Extra-Oral Orthopantomograph (OPG) (Panoramic Radiograph) Transtomography PosteroAnterior Cephalogram Lateral Cephalogram Computed Tomography (CT) Cone-beam Computed Tomography (CBCT).

Special Diagnosis Magnetic resonance imaging (MRI) Dental MRI Rapid prototyping CBCT combined with prototyping.

1. Clark technique: Two intra-oral periapical radiographs are taken using different horizontal angulations. [Same Lingual Opposite Buccal (SLOB) rule]. Horizontal parallax, Vertical Parallax. 2. Southall and Gravely technique: One maxillary anterior occlusal radiograph and one maxillary lateral occlusal radiograph are taken. 3. Rayne technique: This involves differing vertical angulations, with one periapical and one maxillary anterior occlusal radiograph being taken. 4. Keur technique: This is also a vertical parallax method, in which one panoramic and one maxillary anterior occlusal radiograph are taken..

There are methods that use the combination of a lateral cephalogram & a posteroanterior cephalogram or a panoramic radiography & a lateral cephalogram. Becker A , Chaushu S.

Dental MRI (dMRI) is well suited to three-dimensional localization of impacted teeth in children and adults Tymofiyeva O, Rottner K, Jakob PM, Richter E-J, Proff P. Three-dimensional localization of impacted teeth using magnetic resonance imaging. Clin Oral Investig. 2010 Apr;14(2):169–76..

Method for diagnosis and treatment planning of maxillary canine impaction by using computed tomography combined with rapid prototyping. Dental models might become the diagnostic procedure of choice in the evaluation of impacted maxillary canines Faber J, Berto PM, Quaresma M. Rapid prototyping as a tool for diagnosis and treatment planning for maxillary canine impaction. Am J Orthod Dentofacial Orthop. 2006;129(4):583-589. doi:10.1016/j.ajodo.2005.12.015.

New non-invasive and non-radiating real-time chairside imaging method that has the potential to aid in locating the impacted tooth. Lawrence H. Le, Kim-Cuong T. Nguyen, Thanh-Giang La, Vu Duc Nguyen, Minh Binh Le, Punithakumar Kumaradevan, Neelambar Kaipatur, Paul W. Major, and Edmond H. M. Lou ACS Sensors 2024. Yatabe, M., Kripfgans, O., Chan, HL. et al. Ultrasonography as an additional tool to localize impacted canines. Oral Radiol (2024).

Classification of impacted maxillary canines facilitates interdisciplinary communication. Facilitates in management of impacted maxillary canines requires an accurate localization. Canine impactions are broadly classified based on their labio-palatal positions in relation to the alveolar ridge, the axial inclination and the depth of the impacted tooth..

Archer Classification (1975) Class I: Impacted canines in the palate. 1. Horizontal, 2. Vertical, 3. Semivertical Class II: Impacted canines located on the labial surface. 1. Horizontal, 2. Vertical, 3. Semivertical Class III: Impacted canine located labially and palatally crown on one side and the root on the other side. Class IV: Impacted canine located within the alveolar process usually vertically between the incisor and first premolar. Class V: Impacted canine in edentulous maxilla Impacted canine can be in unusual positions like inverted position..

Field and Ackerman Classification (1935) (Maxillary Canines) 1. Labial position Crown in intimate relation with incisors. Crown well above apices of incisors. 2. Palatal position Crown near surface. Crown deeply embedded in close relation to apices of incisors. 3. Intermediate position Crown between lateral incisor and first premolar roots. Crown above these teeth with crown labially placed and root palatally placed or vice versa. 4. Unusual position In nasal or antral wall. In infraorbital region..

Chapokas Classification Relation to the neighboring lateral incisor root was classified by Chapokas, Class I - palatal location Class II - center of the alveolar ridge or labial to the alveolar crest, without labial superimposition to the root of the adjacent lateral incisor Class III labial to the long axis of the adjacent lateral incisor root to decide surgical interventional technique..

Ericson S, Kurol J. Lindauer SJ, Rubenstein LK, Hang WM, et al. Becker. A Ackerman and Fields. Kim Y, Hyun H, Jang K. Power SM, Short MB. Alqerban A, Jacobs R, van Keirsbilck P, et al. Warford JH, Grandhi RK, Tira DE. McSherry PF. Pitt S, Hamdan A, Rock P. Malik D S, Fida M, Sukhia R H. Nagpal A, Pai KM, Setty S, et al. Naoumova J, Kjellberg H..

The Ericson and Kurol; five-sector classification method is based on the location of the canine in relation to the root of the lateral incisor. Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol. 1986;14(3):172-176. doi:10.1111/j.1600-0528.1986.tb01526.x Ericson, S.; Kurol, J. Radiographic examination of ectopically erupting maxillary canines. Am. J. Orthod. Dentofac. Orthop. 1987, 91, 483–492. [CrossRef].

64%. Suggested that extraction of the primary canine is the treatment of choice in young individuals to correct palatally ectopically erupting maxillary canines provided that normal space conditions are present, and no incisor root resorptions are found. Sune Ericson, Jüri Kurol, Early treatment of palatally erupting maxillary canines by extraction of the primary canines, European Journal of Orthodontics, Volume 10, Issue 4, November 1988, Pages 283–295, https://doi.org/10.1093/ejo/10.4.283.

Located the unerupted canine cusp tip relative to the lateral incisor root in one of four sectors using a modified method of Ericson and Kurol. He evaluated the panoramic radiographs taken during the late mixed dentition period and classified them into four sectors..

The Yamamoto et al. seven subtypes classification method is based on the angle between the occlusal plane and the long axis of the tooth. The seven classes are subtypes of canine impaction in which the model proposed in this study is responsible for identifying to which type of impaction the input image belongs. G. Yamamoto, Y. Ohta, Y. Tsuda, A. Tanaka, M. Nishikawa, et al. A new classification of impacted canines and second premolars using orthopantomography Asian J Oral Maxillofac Surg, 15 (1) (2003), pp. 31-37, 10.1016/S0915-6992(03)80029-8.

Ghoneima et al. which classifies the impacted maxillary canine into ten groups (Types A to J) according to their positions and locations. Ghoneima, Ahmed. (2014). Position and Distribution of Maxillary Displaced Canine in a Japanese Population: a Retrospective Study of 287 CBCT Scans. Anatomy & Physiology. 4. 153. 10.4172/2161-0940.1000153..