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Erickosn and Kurol
Erickosn and Kurol
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-
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
or less casual remarks that extraction of the in young individual s. It was also considered of
primary canine may offer a possibility ofcorrect- interest to determine when such a corr ective
ing impacted canines (Hot z, 1974; Howard, effect of the extraction could be ascertained.
1978; Silling et al., 1979). On the other hand,
there is also a case report in which extraction of
Subjects and methods
the primary canine did not affect the eruption
of the permanent canine (Hotz, 1974). Forty-six consecutive ectopic palat ally placed
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
10-10.9 17 37
11-11.9 13 28
12-12.9 16 35
Total 46 100
,
, / I
old at the time of the discovery of the ectopic , , / I I
, , / I I
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
position number after after after after
(orthopantomogram) of canines 6 months 12 months 18 months 18 months
Sector 1,2 24 19 3 2
Sector 3, 4 22 4 10 6 2
Total 46 23 13 8 2
* 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
Registration mean s.d. d±s.d. significance
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
the canines in the youngest age groups with a with orthodontic appliances, while in most other
moderate dislocation of the canine might have cases a further 6 months of observation may be
corrected spontaneously, as shown by us earlier allowed. If no improvement is detectable at
(Ericson and Kurol, 1986a). For ethical reasons, the 12-month control, we suggest alternative
we have not 'been able to design a study with a treatment. If the diagnosis is made early accord-
traditional, untreated control group but it is ing to defined criteria i.e. clinical palpation and
hardly likely that 22 of 24 canines (92%) in if necessary radiographic examination (Ericson
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
ines in most cases, if this extraction treatment 69: 371-387
is performed in time. Early diagnosis ofmaler up- Boyd R L 1982 Clinical assessment of injuries in orthodontic
movement of impacted teeth. American Journal of Ortho-
tion is important for success. The ectopic pos- dontics 82: 478-486
ition and the path of eruption of the maxillary
Buchner H J 1936 Root resorption caused by ectopic
canine should preferably be identified before the eruption of maxillary cuspid. International Journal of
age of 11. Orthodontia 22: 1236-7
When a favourable effect of treatment occurs, Clark D 1971 The management of impacted canines: free
the change in position and in the path of eruption physiologic eruption. Journal of the American Dental
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
in periodontal breakdown of treated palatally impacted Practitioner 19: 194-204
canines. American Journal of Orthodontics 85: 72-77 Richardson A, McKay C 1982 Delayed eruption of maxillary
Lappin M M 1951 Practical management of the impacted canine teeth. Part I-Aetiology and diagnosis. Proceed-
maxillary cuspid. American Journal of Orthodontics 37: ings of the British Paedodontic Society 12: 15-25
769-778 Richardson A, McKay C 1983Delayed eruption of maxillary
Leivesley W D 1984 Minimizing the problem of impacted canine teeth. Part 2-Treatment. Proceedings of the
and ectopic canines. Journal of Dentistry for Children 51: British Paedodontic Society 13: 13-23
367-370 Salzmann J A 1974 Orthodontics in daily practice. J B
Lind V 1977Ortodontisk bettvard VII. Overkakshdrntandens Lippincott Company, Philadelphia p 339