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Ericson 1988
Ericson 1988
SUMMARY 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 10.0-
13.0 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.
however , only a slight displacement of the canine on the palat ally deflected pa th of eruption of
is present in the periapical intra-oral radio- maxillar y canines has been carried out, however.
graphs, for example with the crown in a good Th e purpose of this pro spective study was to
position but with an increased mesial angulation analyse the effect of extrac tion of the primary
(Kett le, 1957). Other authors have made more can ine on palatally erupting maxillary canines
Figure I Orthopan tomogram (A), int ra-oral axial-vertex radiogra ph (B) and int ra-oral periapical films (C) showing the left
maxillary perma nent canine in a true palat al ectopic path of eruption and the right canine with a lingual tendency. At the
sta rt of treatment, the primar y canines arc present. No rmal space conditions. Normalizatio n of the left canine 6 months
afte r extractio n of the primary canine (D).
ECTOPIC MAXILLARY CANINES 285
Total 46 100
,
, / I
old at the time of the discovery of the ectopic , , / I I
, , / I I
position (Table 1)and were referred for treatment '2'3/4/51
from the Public Dental Service after the intro-
duction of a digital palpation screening method
(Ericson and Kurol, 1986b). Inability to locate
the canine in the normal position by digital Sector 1 2 3 4 5
palpation prompted a supplementary radio-
graphic examination of the canine, where its Number 13 11 20 2 o
position was carefully determined in three planes
(Ericson and Kurol, 1986a, Fig. 1).
The eruption angles and positions of the
1
,
/
:5
Sector 123 4 5
Number 8 1817 3 o
Figure 3 Distribution ofthe 46 maxillary canines according
(1" d1 to the medial position of the canine crown in sectors 1-5 in
(degrees) (mm) the (A) frontal plane and (B) transverse plane (derived from
orthopantomogram and axial-vertex views) at the start of
treatment.
Mean 22.0 14.7
s.d. 11.1 3.2 permanent maxillary canines were determined
Range 2-55 9.5-20.3 as follows:
- In the frontal view (orthopantomogram) (A)
Figure 2 Mesial inclination (alpha, ex) to the midline and
distance (dl) to the occlusal line, OL, of the permanent the angle of the canine (B) the distance of the
maxillary canine in the frontal plane (orthopantomogram) cusp tip to the occlusal line (Fig. 2) and the
at the start of treatment. 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 Total No change Worsening
Sector 1,2 24 19 3 2
Sector 3, 4 22 4 10 6 2
Total 46 23 13 8 2
-In the transverse plane (vertex projection) the Conventional statistical methods were used
position of the crown of the canine relative to for calculation of means and standard devi-
the adjacent lateral incisor and dental arch ations. Student's z-test was used for parametric
was determined from the vertex projection variables and the chi-square test for non-para-
and the conventional intra-oral projections. metric variables for the analysis of differences
The position of the canine crown relative to between the registrations (Nie et al., 1975).
the dental arch was classified as completely
lingual, lingual tendency and correctly pos-
itioned. Results
- In the sagittal plane (lateral head film), the The main results are presented in Table 2.
distances to the occlusal line. Altogether 36 (78%) of the 46 ectopic canines
Immediately after diagnosis of the ectopic showed normalization of the path of eruption
palatal path of eruption, the primary canine was and later clinically correct position at the final
extracted. The permanent canines were then control. For ten teeth no improvement was
followed clinically and radiographically at six- registered: seven showed no change at all, one
month intervals up to 18 months for the radio- only slight improvement and two an impaired
graphic procedure, if necessary, and clinically position with the crown moving more medially
to full eruption or to the end of necessary during the observation period.
orthodontic appliance treatment. Thus, if a
clearly noticeable improvement of the position Time/actor
of the maxillary permanent canine was regis- Of the 36 cases with normalization and clinically
tered, the radiographic follow-up was termi- correct position at the final control, 23 canines
nated at the 6 or 12-month control. (64%) already showed improved positions radio-
In four of the 46 cases (one boy and three graphically at the 6-month control, Table 2.
girls), the lateral incisors already showed root Nine of these had already normalized at this
resorption on the palatal side at start. Two of time (for example, Fig. 1). After 12 months,
the resorptions were superficial and two were another 13 teeth had normalized and another
extensive and reached the pulp. In the latter two 14 canines had improved positions and showed
cases, the treatment planning for orthodontic clinically good positions at the 18-month con-
treatment of their malocclusion included extrac- trol. No new cases of improvement occurred
tion of maxillary teeth and these two cases were between the 12-month and 18-month obser-
therefore included in this study. vations.
The maximum width of the dental follicle
of the canine was measured on the intra-oral Medial position (sectors 1-5, Fig. 3)
periapical radiographs. Of the 46 canines, 22 overlapped the adjacent
All cases had good dental arches and no space lateral incisor (in the orthopantomogram) by
deficiency was registered after measuring with more than half of the lateral root, and 14 (64%)
sliding calipers. There had been no early extrac- of these normalized (Table 3). Of the 24 canines
tion of primary molars in the maxilla. which overlapped the lateral incisor root by less
ECTOPIC MAXILLARY CANINES 287
* 9 canines had normal positions at the 6-month radiographic control and another 13 at
the 12-month control.
Central
Palatal or buccal
Registration Palatal tendency tendency Total number
than half of the root at the start of treatment, 3) showed concordant results and will not be
22 (91 %) normalized (Table 2, Fig. 4). The reported in detail.
change in medial canine crown position in re-
lation to time after extraction can be seen from Position relative to the dental arch
Table 3, where eight of the ten teeth with no The distribution of the canine crown position
final normalization belonged to sectors 3 and 4 relative to the midline of the dental arch is
and one to sector 2 at the start. The positions shown in Table 4. Of the 27 canines (59%) in a
of the canines in the vertex projection (Fig. lingual position at the start of treatment (22 in
288 SUNE ERICSON AND JURI KUROL
10
Level of
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.
Level of
Registration mean s.d. d±s.d. significance
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.
Orthodontic
Position in the impaired surgical fixed appliance Extraction
orthopantomogram No change position exposure treatment of lateral
Overlapping
less than half
of the
lateral (sectors 1, 2) 2
Overlapping
more than
half of the
lateral (sectors 3, 4) 6 2 8 8 2
Total 8 2 9 8 2
290 SUNE ERICSON AND JURI KUROL
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 pala- Figure 6 Ectopic palatal eruption of the right maxillary
tally erupting maxillary canines has been shown. canine in a girl aged 12 years 9 months at the start of
Orthodontic textbooks and papers on treatment treatment. The mesial inclination and palatal position where
of ectopic maxillary canines do not mention this the canine crown almost reaches the centr al incisor can
be seen in the orthopantornogram (A) and axial vertex
treatment approach, but there are sparse case projection (B). The radiographs show the improvement of
reports in the literature (Buchner, 1936; Kettle, position and inclination from the start of treatment (C) to
1957; Lind, 1977; Williams, 1981; Leivesley, 6 months after extraction of the primary canine (D, E).
ECTOPIC MAXILLAR Y CANINES 291
clinical experience, it is not likely that ectopically or improved positions. If such a change in
erupting canines will be spontaneously corrected eruption is not detectable at that time, a new
to such an extent, especially not those with the decision must be made and some canines posing
crown in advanced medial positions, as shown a risk of further root resorption of the incisors,
in Figures 2 and 4, Table 2. However, a few of may have to be surgically exposed and treated
Figure 7 Palatal ectopic eruption of both maxillary canines in a boy aged 12 years II months at the start of treatment.
Mixed dentition period. The width of the dental follicle exceeded 3 mm for both canines. In 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 (C) 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 ERICSO N AND J URI KUROL
and angul ations may react differentl y even in can ine is then higher up and probabl y has a less
the same individual, as shown in Figure 7. In deflected path of eruption . Note that one-third
spite of a difference of only four degrees in of the patients in this study were between 12
mesial angul ation and concordant medial and and 13-years-old at the time of referral.
lingual positions, the left maxillary canine nor- It has often been mentioned that a palatal
malized but not the right. Due to the difficulty path of eruption may be seen in cases where the
in predicting a favourable change of the path of primary canine is unresorbed (Dewel, 1949;
eruption in the individual case, we recommend Hotz, 1974; Salzmann, 1974). H owever, it is not
radiological and/or clinical supervision at six- established whether this is a con sequence or the
month intervals after extraction of the primary primary cause of the ectop ic palat al eruption.
canine until the permanent canin e erupts. In this study, in individuals aged 10-13 years ,
The degree of palatal position at the start of i.e. during a normal eruption period, 21 (46%)
treatment relative to the dent al arch has been of the 46 primary canines were unr esorbed and
shown to influence the result (Table 4). Maxillary 25 (54%) showed various degree s of resorption.
canin es with a moderate lingual path of eruption In order to be successful with this procedure
normalized more often (90%) than canines in of extracting the prim ar y canine, we must follow
true lingual positions (65%). Again , no reliable the eruption pro cess radiologically by means of
forecast of success or failure can be made in the correct and standardized radiographs. If this is
individual case, although the prognosis for the done , it will be possible to record even slight or
treatment on the whole is very good. With earlier mod erate chan ges, as studies of distortion in
diagno sis according to our earlier recommen- rotational panoramic radiography and cephalo-
dations (Ericson and Kurol , 1986b), it may be graphy have demonstrated great tolerance with
possible to achieve even better results as the respect to angular and vertical distorti ons
ECTOPIC MAXILLAR Y CANINES 293
(Tronje, 1982; McDavid et al., 1985; Ahlqvist et crowding and in cases of resorption or very
al., 1986). Based on these reports, and applying horizontal paths of eruption, alternative modes
a relative scale for the mesio-distal and bucco- of treatment should be considered, as our experi-
lingual determinations, it can be claimed that ence of the method in such cases is too small.
the registrations in this study have been per- Surgical exposure with subsequent orthodontic
formed with moderate errors, acceptable for appliance treatment will be the main choice in
practical clinical purposes in the everyday clini- those cases.
cal situation. Used together, we consider the Early extraction of the primary canine in order
methods describe the displaced canine and the to correct the malerupting maxillary permanent
changes in position with sufficient accuracy in canine has considerable advantages for the child,
three dimensions and are suitable for this clinical both economically and in terms of the discomfort
purpose. Guilford's coefficient of reliability that result from more traditional treatment ap-
(Guilford, 1965) was high for all our measure- proaches. In fact, periodontal damage to the
ments (Ericson and Kurol, 1988). ectopic canine after surgical exposure and ortho-
In view of the positive results of this study we dontic alignment has been reported compared
suggest that primary canine extraction is the to control canines (Wisth et al., 1976 a,b; Hans-
trea tment of choice in the age-group 10-13 years son and Linder-Aronson, 1972; Boyd, 1982;
when the permanent maxillary canine has a Kohavi et al., 1984; Oliver and Hardy, 1986).
palatal ectopic path of eruption. Before the age Incisor devitalization and some loss of alveolar
of 10, spontaneous correction of potentially bone support may also occur (Proffit and Acker-
malplaced canines may occur (Ericson and man, 1985).
Kurol, 1986b) and extraction is normally not The characteristics of those cases wi th no
indicated unless a very early somatic and dental change or an impaired position have to be
development is found. With late diagnosis or further analysed.
294 SUNE ERICSON AND JURI KUROL
Conclusions and recommendations Berger H 1943 Idiopathic root resorption. American Journal
of Orthodontics and Oral Surgery 29: 548-549
It has been clearly shown that extraction of Bishara S E, Kommer D D, McNeil M H, Montagano
primary canines in the upper jaw has a favour- L N, Oesterle L J, Youngquist H W 1976 Management
able effect on palatally erupting maxillary can- of impacted canines. American Journal of Orthodontics
Kettle M A 1957 Treatment of the unerupted maxillary Proffit W R, Ackerman J L 1985 Diagnosis and treatment
canine. Transactions of the British Society for the Study planning. In: Orthodontics. Current principles and tech-
of Orthodontics 74-84 niques. Edited by Graber T M, Swain B F. The C V
Kohavi D, Becker A, Zilberman Y 1984 Surgical exposure, Mosby Company, St Louis p 95
orthodontic movement, and final tooth position as factors Rayne J 1969 The unerupted maxillary canine. Dental
Practitioner 19: 194-204