European Journal of Orthodontics 10 (1988) 283-295

1988 European Orthodontic Society

Early treatment of palatally erupting maxillary canines

by extraction of the primary canines
Sune Ericson and Juri Kurol
Jonkoping, Sweden
The effect of extraction of the primary canine on palatally erupting ectopic maxillary
canines was analysed. There were 46 consecutive ectopic canines, in 35 individuals, aged 10.013.0 years (mean age 11.4 years) at the time of discovery of the ectopic eruption. All cases
showed no or minor space loss. After extraction of the primary canine, the children were
investigated clinically and radiographed at 6-month intervals for up to 18 months.
In 36 of the 46 canines (78%) the palatal eruption changed to normal; 23 already showed
improved positions after 6 months and 13 after 12 months. No new cases normalized after 12
months.
We suggest 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.
SUMMARY

Introduction
The maxillary permanent canine is second only
to the third molar in frequency of impaction,
with a prevalence of approximately 2 per cent
of the population (Thilander and Jakobsson,
1968; Ericson and Kurol, 1986a). The canine is
found palatal to the dental arch in about 85
percent of the cases and buccal only in about 15
percent (Hitchin, 1956; Rayne, 1969; Ericson
and Kurol, 1987a).
If orthodontic treatment is not started, there
is always a risk of retention and also of resorption of the roots of the permanent incisors. Such
resorptions have recently been reported to occur
in 12 percent of cases of ectopic eruption of the
maxillary canines in the age range 10-13 years
(Ericson and Kurol, 1987a). Resorptions may
be found as early as 10 years of age but occur
most often in the age groups 11 to 12 years
(Ericson and Kurol, 1987b).
The most common treatment procedure in
children and adolescents is surgical exposure
followed by orthodontic appliance treatment,
where, as a rule, the primary canines are left in
place until the orthodontist has moved the
impacted tooth to this region (Moyers, 1973;
Clark, 1971; Bishara et al., 1976; Hunter,
1983a, b; Fleury et al., 1985). Other proposed

strategies are 1. acceptance, i.e. no treatment, 2. extraction of the malerupting canine,

and 3. surgical repositioning (Richardson and
McKay, 1983).
Several aetiological factors for ectopic canine
eruption have been proposed, and include hereditary factors, lack of space, persistence of
primary canines, a true ectopic path of eruption,
reduced root length or aplasia of lateral incisors
(Richardson and McKay,. .1982; Jacoby, 1983;
Becker et al., 1984).
Delayed exfoliation of the primary canine was
believed by Lappin (1951) to be the principal
aetiological factor and he presumed that it
would be possible to prevent the condition from
occurring in a great many cases, by extracting
the primary canine. This was also suggested by
Miller (1963) and Williams (1981). Berger, in
1943, stated that widening of the arch in the
premolar region and early extraction of the
primary canines were advisable as precautionary
measures to prevent incisor root resorptions.
A thorough search of the literature has shown
that sporadic case reports where extraction of
the primary canine has favourably influenced
the future path of eruption have been presented over the last 50 years (Buchner, 1936;
Kettle, 1957; Lind, 1977; Williams, 1981; Leivesley, 1984). In some of the presented case reports,

284

however, only a slight displacement of the canine

is present in the periapical intra-oral radiographs, for example with the crown in a good
position but with an increased mesial angulation
(Kettle, 1957). Other authors have made more
or less casual remarks that extraction of the
primary canine may offer a possibility of correcting impacted canines (Hotz, 1974; Howard,
1978; Silling et al., 1979). On the other hand,
there is also a case report in which extraction of
the primary canine did not affect the eruption
of the permanent canine (Hotz, 1974).
No systematic longitudinal study to evaluate
the corrective effect of primary canine extraction

SUNE ERICSON AND JURt KUROL

on the palatally deflected path of eruption of

maxillary canines has been carried out, however.
The purpose of this prospective study was to
analyse the effect of extraction of the primary
canine on palatally erupting maxillary canines
in young individuals. It was also considered of
interest to determine when such a corrective
effect of the extraction could be ascertained.
Subjects and methods
Forty-six consecutive ectopic palatally placed
maxillary canines were studied. The children, 14
boys and 21 girls, were between 10 and 13 years

Figure 1 Orthopantomogram (A), intra-oral axial-vertex radiograph (B) and intra-oral periapical films (C) showing the left
maxillary permanent canine in a true palatal ectopic path of eruption and the right canine with a lingual tendency. At the
start of treatment, the primary canines are present. Normal space conditions. Normalization of the left canine 6 months
after extraction of the primary canine (D).

285

ECTOPIC MAXILLARY CANINES

Table 1 Distribution according to age at the

time of extraction of the primary canine.
Age-group

Number of teeth

Percent

10-10.9
11-11.9
12-12.9

17
13
16

37
28
35

Total

46

100

old at the time of the discovery of the ectopic

position (Tablel) and were referred for treatment
from the Public Dental Service after the introduction of a digital palpation screening method
(Ericson and Kurd, 1986b). Inability to locate
the canine in the normal position by digital
palpation prompted a supplementary radiographic examination of the canine, where its
position was carefully determined in three planes
(Ericson and Kurol, 1986a, Fig. 1).
The eruption angles and positions of the

Sector
Number

13

11

20

18

17

Sector
Number
di

(degrees)

(mm)

Mean

22.0

14.7

s.d.
Range

2-55

11.i

3.2
9.S-2O.3

Figure 2 Mesial inclination (alpha, a) to the midline and

distance (dl) to the occlusal line, OL, of the permanent
maxillary canine in the frontal plane (orthopantomogram)
at the start of treatment.

Figure 3 Distribution of the 46 maxillary canines according

to the medial position of the canine crown in sectors 1-5 in
the (A) frontal plane and (B) transverse plane (derived from
orthopantomogram and axial-vertex views) at the start of
treatment.

permanent maxillary canines were determined

as follows:
In the frontal view (orthopantomogram) (A)
the angle of the canine (B) the distance of the
cusp tip to the occlusal line (Fig. 2) and the
medial crown position in sectors 1 -5 (Fig. 3).

286

SUNE ERICSON AND JURI KUROL

Table 2 Effect of the extraction of the primary canine on the 46 maxillary canines with a palatally ectopic
path of eruption in 35 individuals, 14 boys and 21 girls, aged 10-13 years.
Improved position

Canine
position
(orthopantomogram)

Total
number
of canines

after
6 months

after
12 months

No change
after
18 months

Worsening
after
18 months

Sector 1, 2
Sector 3, 4

24
22

19
4

3
10

2
6

Total

46

23

13

In the transverse plane (vertex projection) the

position of the crown of the canine relative to
the adjacent lateral incisor and dental arch
was determined from the vertex projection
and the conventional intra-oral projections.
The position of the canine crown relative to
the dental arch was classified as completely
lingual, lingual tendency and correctly positioned.
In the sagittal plane (lateral head film), the
distances to the occlusal line.
Immediately after diagnosis of the ectopic
palatal path of eruption, the primary canine was
extracted. The permanent canines were then
followed clinically and radiographically at sixmonth intervals up to 18 months for the radiographic procedure, if necessary, and clinically
to full eruption or to the end of necessary
orthodontic appliance treatment. Thus, if a
clearly noticeable improvement of the position
of the maxillary permanent canine was registered, the radiographic follow-up was terminated at the 6 or 12-month control.
In four of the 46 cases (one boy and three
girls), the lateral incisors already showed root
resorption on the palatal side at start. Two of
the resorptions were superficial and two were
extensive and reached the pulp. In the latter two
cases, the treatment planning for orthodontic
treatment of their malocclusion included extraction of maxillary teeth and these two cases were
therefore included in this study.
The maximum width of the dental follicle
of the canine was measured on the intra-oral
periapical radiographs.
All cases had good dental arches and no space
deficiency was registered after measuring with
sliding calipers. There had been no early extraction of primary molars in the maxilla.

Conventional statistical methods were used

for calculation of means and standard deviations. Student's /-test was used for parametric
variables and the chi-square test for non-parametric variables for the analysis of differences
between the registrations (Nie et al., 1975).
Results
The main results are presented in' Table 2.
Altogether 36 (78%) of the 46 ectopic canines
showed normalization of the path of eruption
and later clinically correct position at the final
control. For ten teeth no improvement was
registered: seven showed no change at all, one
only slight improvement and two an impaired
position with the crown moving more medially
during the observation period.
Time factor
Of the 36 cases with normalization and clinically
correct position at the final control, 23 canines
(64%) already showed improved positions radiographically at the 6-month control, Table 2.
Nine of these had already normalized at this
time (for example, Fig. 1). After 12 months,
another 13 teeth had normalized and another
14 canines had improved positions and showed
clinically good positions at the 18-month control. No new cases of improvement occurred
between the 12-month and 18-month observations.
Medial position {sectors 1-5, Fig. 3)

Of the 46 canines, 22 overlapped the adjacent

lateral incisor (in the orthopantomogram) by
more than half of the lateral root, and 14 (64%)
of these normalized (Table 3). Of the 24 canines
which overlapped the lateral incisor root by less

ECTOPIC MAXILLARY CANINES

287

Table 3 Distribution of the medial position of the maxillary permanet canine in

sectors 1-4 in the vertical plane as shown in the orthopantomogram. No teeth
were in sector 5. At the start of treatment, after 12 and after 18 months. Number
and percent.
Medial maxillary canine crown
position in sector

3.4

Total number

n(%)
13(28)

n(%)
11(24)

n(%)
22(46)

46

12 months
after
extraction
(n = 37)

28*(61)

9(20)

9(20)

46*

18 months
after
extraction
(n = 24)

36*(78)

2(4)

8(17)

46*

Registration
At start
(n = 46)

* 9 canines had normal positions at the 6-month radiographic control and another 13 at
the 12-month control.

Table 4 The distribution of the canine crown position relative to the

midline of the dental arch in the horizontal plane as shown in the axialvertex radiogram. At the start of treatment, 12 months and 18 months
after extraction of the primary canine. Number and percent.
Position relative to the dental arch
Central
or buccal
tendency

Palatal

Palatal
tendency

n(%)
27(59)

n(%)
19(41)

n(%)

12 months
after extraction
(n = 37)

9(20)

15(33)

22(48)*

46*

18 months
after extraction
(n = 24)

8(17)

2(4)

36(78)*

46*

Registration
At start
(n = 46)

Total number

46

* 9 canines had normal positions at the 6-month radiographic control and

another 13 at the 12-month control.

than half of the root at the start of treatment,

22 (91%) normalized (Table 2, Fig. 4). The
change in medial canine crown position in relation to time after extraction can be seen from
Table 3, where eight of the ten teeth with no
final normalization belonged to sectors 3 and 4
and one to sector 2 at the start. The positions
of the canines in the vertex projection (Fig.

3) showed concordant results and will not be

reported in detail,
Position relative to the dental arch
The distribution of the canine crown position
relative to the midline of the dental arch is
shown in Table 4. Of the 27 canines (59%) in a
lingual position at the start of treatment (22 in

288

SUNE ERICSON AND JURI KUROL

could be seen for eight of the canines at the last

control at 18 months. All the rest normalized
except one, which remained in a slight lingual
position (lingual tendency). This means complete
normalization in 78% of all cases.
Mesial inclination

The distribution of the mesial inclination of the

maxillary canines at the start of treatment is
shown in Figure 5. The inclination is approximately normally distributed. The change after
extraction of the primary canines at the 6-month
and 12-month controls is shown in Table 5.
The dynamic change in position and the mean
difference at the different registrations are
presented. Note the large standard deviations
(Table 5).
Canine vertical distance to the occlusal plane
I
Figure 4 Schematic illustration of the normalization of the
maxillary permanent canine at the control 18 months after
extraction of the primary canines. The figures indicate the
rate of success for the permanent canine positions at the
start of treatment, mesial and distal to the midline of
the lateral incisor in the orthopantomogram.

sectors 3 and 4, and 5 in sectors 1 and 2) only

9 (20%) remained in this position and no change

The distance from the canine cusp to the occlusal

plane (Fig. 2) at the different registrations is
shown in Table 6. The distance at the start of
treatment ranged from 9.5 to 20.3 mm. At that
time, the canines were on average positioned
about 15 mm from the occlusal line in the
orthopantomogram and Table 6 shows the
change during the observation period up to
12 months. The distance as measured on the
lateral head film showed concordant results
compared to Table 6.

10-

O*-4*

5*-9*

ll

15'-19* 20T-24" 25'-29* 3O'-34* 35*-39# 40*"44* 45'-49' 5O'-S5"

Mesial inclination to the midline

(orthopantomogram)
Figure 5 Distribution of the mesial inclination (degrees) of the 46 maxillary canines to the midline in the orthopantomogram
at the start of treatment

289

ECTOPIC MAXILLARY CANINES

Table 5 Mesial inclination (degrees) of the canine to the midline in the
orthopantomogram. Mean value and standard deviation at the different
registrations and mean difference and level of significance.
Registration

s.d.

ds.d.

Level of
significance

At start
(n = 46)

22.0

11.1

6-month
control
(n = 46)

17.9

12.5

4.1+8.3

p < 0.01

12-month
control
(n = 37)

14.0

13.3

9.8 + 9.1

p < 0.001

Table 6 The distance (mm) from the canine cusp to the occlusal plane
in the orthopantomogram. Mean value and standard deviation at the
different registrations and mean difference and level of significance.
ds.d.

Level of
significance

4.3

3.0 1.8

p < 0.01

5.0

5.5 2.7

p < 0.001

Registration

mean

s.d.

At start
(n = 46)

14.7

3.2

6-month
control
(n = 46)

11.7

12-month
control
(n = 37)

9.2

Table 7 Treatment procedures for 10 out of the 46 ectopic maxillary canines where no
improvement of position was registered 12 months after extraction of the primary canine.
Change of eruption path

Treatment

No change

impaired
position

surgical
exposure

Orthodontic
fixed appliance
treatment

Overlapping
more than
half of the
lateral (sectors 3, 4)

Total

Position in the
orthopantomogram

' Extraction
of lateral

Overlapping
less than half
of the
lateral (sectors 1, 2)

290
No normalisation
Ten of the 46 canines showed no change or
an impaired position. The clinical treatment is
shown in Table 7. Nine of these teeth had a true
lingual position at the start of treatment (Table
4) and in eight cases the cusp was positioned
more medially to the midline of the lateral incisor
in the orthopantomogram. Surgical exposure
and orthodontic fixed appliance treatment was
carried out in eight cases (Table 7). After orthodontic treatment, all canines were in clinically
favourable positions.

SUNE ERICSON AND JURI KUROL

1984). Perhaps extraction of the primary canine

has been considered an 'oddity' and the success
limited to cases with only a minor deflection, as
shown by Kettle (1957).
This study clearly shows that extraction of
the primary canine has a favourable effect on
palatally malerupting maxillary canines. Almost
80 per cent of the cases were corrected due to
the early extraction of the primary canines.
Spontaneous corrections may occur but from

Resorptions
In the four cases with resorptions on the root
of the lateral incisor, diagnosed at the start of
treatment, the positions were normal in two
cases, unchanged in one and one canine showed
an impaired position. Three canines were positioned in sector 3 and one in sector 2 in the
orthopantomogram at the start of treatment.
Two of the resorptions were severe and reached
the pulp at the start of treatment. One remained
unchanged and one deteriorated during the
observation period and these two cases are the
extraction cases, where the orthodontic treatment plan included extraction of lateral incisors
as one possibility from the start. No new cases
of resorption were registered during the observation period.
Dental follicle
The maximal width of the dental follicle of the
maxillary canine, measured on the intra-oral
periapical radiographs, exceeded 3 mm in 13
cases and varied between 1 and 5 mm for the
46 canines. There was no association in those
cases which did not improve related to the size
of the follicle.
Discussion
The effect of extraction of the primary canine
on the palatally deflected path of eruption of
the maxillary canine, is analysed in this report.
To our knowledge, this is the first prospective
longitudinal study where such an effect on palatally erupting maxillary canines has been shown.
Orthodontic textbooks and papers on treatment
of ectopic maxillary canines do not mention this
treatment approach, but there are sparse case
reports in the literature (Buchner, 1936; Kettle,
1957; Lind, 1977; Williams, 1981; Leivesley,

Figure 6 Ectopic palatal eruption of the right maxillary

canine in a girl aged 12 years 9 months at the start of
treatment. The mesial inclination and palatal position where
the canine crown almost reaches the central incisor can
be seen in the orthopantomogram (A) and axial vertex
projection (B). The radiographs show the improvement of
position and inclination from the start of treatment (C) to
6 months after extraction of the primary canine (D, E).

ECTOPIC MAXILLARY CANINES

clinical experience, it is not likely that ectopically

erupting canines will be spontaneously corrected
to such an extent, especially not those with the
crown in advanced medial positions, as shown
in Figures 2 and 4, Table 2. However, a few of
the canines in the youngest age groups with a
moderate dislocation of the canine might have
corrected spontaneously, as shown by us earlier
(Ericson and Kurol, 1986a). For ethical reasons,
we have not been able to design a study with a
traditional, untreated control group but it is
hardly likely that 22 of 24 canines (92%) in
sectors 1 and 2 and 14 of 22 (64%) in sectors 3
and 4 (in the orthopantomogram) would do so.
The results will be discussed with this assumption
and reservation.
A positive change in the path of eruption
could be observed radiographically in 50 per
cent of the cases, and in some cases (20%)
also clinically, at the 6-month registration after
extraction of the primary canine (Figs. 1 and 6).
At the 12-month control, all but nine had normal

291
or improved positions. If such a change in
eruption is not detectable at that time, a new
decision must be made and some canines posing
a risk of further root resorption of the incisors,
may have to be surgically exposed and treated
with orthodontic appliances, while in most other
cases a further 6 months of observation may be
allowed. If no improvement is detectable at
the 12-month control, we suggest alternative
treatment. If the diagnosis is made early according to denned criteria i.e. clinical palpation and
if necessary radiographic examination (Ericson
and Kurol, 1986a), there should be enough
time to carry out alternative surgical and/or
orthodontic treatment.
This study has clearly demonstrated the
favourable effect on the maxillary canine even
in very medial positions of the canine crown
(Table 3, Figs. 1 and 6) and up to a mesial
inclination of the canine of 55 degrees to the
midline in the orthopantomogram (Table 6).
Note that canine teeth with similar positions

Figure 7 Palatal ectopic eruption of both maxillary canines in a boy aged 12 years 11 months at the start of treatment
Mixed dentition period. The width of the dental follicle exceeded 3 mm fpr both canines. ID the orthopantomogram (A) the
mesial inclination to the midline is 31 degrees for the left canine and 27 degrees for the right canine. In the axial-vertex
projection (B) the cusp tips are positioned approximately in the same position lingually to the lateral incisor root Twelve
months after extraction of the maxillary primary canines the orthopantomogram ( Q and axial-vertex projection (D) show
an improved position of the left canine and a slightly impaired position of the right maxillary canine.

292

SUNE ER1CS0N A N D JURI KUROL

Figure 8 Girl aged 12 years 8 months at the start of treatment. The right maxillary canine is erupting palatally and the
orthopantomograms, axial-vertex radiographs and intra-oral radiographs show the development from the start (A, C, E) to
12 months after extraction of the primary canine (B, D, F).

and angulations may react differently even in

the same individual, as shown in Figure 7. In
spite of a difference of only four degrees in
mesial angulation and concordant medial and
lingual positions, the left maxillary canine normalized but not the right. Due to the difficulty
in predicting a favourable change of the path of
eruption in the individual case, we recommend
radiological and/or clinical supervision at sixmonth intervals after extraction of the primary
canine until the permanent canine erupts.
The degree of palatal position at the start of
treatment relative to the dental arch has been
shown to influence the result (Table 4). Maxillary
canines with a moderate lingual path of eruption
normalized more often (90%) than canines in
true lingual positions (65%). Again, no reliable
forecast of success or failure can be made in the
individual case, although the prognosis for the
treatment on the whole is very good. With earlier
diagnosis according to our earlier recommendations (Ericson and Kurol, 1986b), it may be
possible to achieve even better results as the

canine is then higher up and probably has a less

deflected path of eruption. Note that one-third
of the patients in this study were between 12
and 13-years-old at the time of referral.
It has often been mentioned that a palatal
path of eruption may be seen in cases where the
primary canine is unresorbed (Dewel, 1949;
Hotz, 1974; Salzmann, 1974). However, it is not
established whether this is a consequence or the
primary cause of the ectopic palatal eruption.
In this study, in individuals aged 10-13 years,
i.e. during a normal eruption period, 21 (46%)
of the 46 primary canines were unresorbed and
25 (54%) showed various degrees of resorption.
In order to be successful with this procedure
of extracting the primary canine, we must follow
the eruption process radiologically by means of
correct and standardized radiographs. If this is
done, it will be possible to record even slight or
moderate ehanges, as studies of distortion in
rotational panoramic radiography and cephalography have demonstrated great tolerance with
respect to angular and vertical distortions

ECTOPtC MAXILLARY CANINES

293

Figure 9 Girl aged 11 years at the start or treatment (A, C, E) and 12 months later (B, D, F); an impaired position of the
left maxillary canine is evident in the orthopantomogram, axial-vertex projection and intra-oral radiograph.

(Tronje, 1982; McDavid et al., 1985; Ahlqvist et

al., 1986). Based on these reports, and applying
a relative scale for the mesio-distal and buccolingual determinations, it can be claimed that
the registrations in this study have been performed with moderate errors, acceptable for
practical clinical purposes in the everyday clinical situation. Used together, we consider the
methods describe the displaced canine and the
changes in position with sufficient accuracy in
three dimensions and are suitable for this clinical
purpose. Guilford's coefficient of reliability
(Guilford, 1965) was high for all our measurements (Ericson and Kurol, 1988).
In view of the positive results of this study we
suggest that primary canine extraction is the
treatment of choice in the age-group 10-13 years
when the permanent maxillary canine has a
palatal ectopic path of eruption. Before the age
of 10, spontaneous correction of potentially
malplaced canines may occur (Ericson and
Kurol, 1986b) and extraction is normally not
indicated unless a very early somatic and dental
development is found. With late diagnosis or

crowding and in cases of resorption or very

horizontal paths of eruption, alternative modes
of treatment should be considered, as our experience of the method in such cases is too small.
Surgical exposure with subsequent orthodontic
appliance treatment will be the main choice in
those cases.
Early extraction of the primary canine in order
to correct the malerupting maxillary permanent
canine has considerable advantages for the child,
both economically and in terms of the discomfort
that result from more traditional treatment approaches. In fact, periodontal damage to the
ectopic canine after surgical exposure and orthodontic alignment has been reported compared
to control canines (Wisth et al., 1976 a,b; Hansson and Under-Aronson, 1972; Boyd, 1982;
Kohavi et al., 1984; Oliver and Hardy, 1986).
Incisor devitalization and some loss of alveolar
bone support may also occur (Proffit and Ackerman, 4985).
The characteristics of those cases with no
change or an impaired position have to be
further analysed.

294
Conclusions and recommendations

It has been clearly shown that extraction of

primary canines in the upper jaw has a favourable effect on palataUy erupting maxillary canines in most cases, if this extraction treatment
is performed in time. Early diagnosis of maleruption is important for success. The ectopic position and the path of eruption of the maxillary
canine should preferably be identified before the
age of 11.
When a favourable effect of treatment occurs,
the change in position and in the path of eruption
will be observed at the latest 12 months after
the extraction of the primary canine. If no
improvement can be found at that time, normalization is not to be expected and alternative
treatment should be considered. Due to the
great individual variation in the position of the
maxillary canines at the start of treatment and
to some extent also in the response to treatment,
it is not possible to predict success or failure in
the individual case, although the prognosis for
the treatment on the whole is very good. Clinical
and/or radiological controls at six-month intervals are recommended.
In view of the positive results, we suggest that
primary canine extraction is the treatment of
choice in the age-group 10-13 years when the
erupting permanent maxillary canine has a palatal ectopic path of eruption. With later diagnosis
or crowding, and in cases of resorption of
the incisor roots or a very horizontal path of
eruption, alternative modes of treatment should
be considered.
Address for correspondence:

Dr Juri Kurol
Department of Orthodontics
The Institute for Postgraduate Dental Education
Jarnvagsgatan 9
S-552 55 Jonkoping
Sweden
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SUNE ERICSON AND JURI KUROL

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