CASE REPORT

Orthodontic repositioning of a lingually

positioned transmigrated mandibular
canine
Andrea Scribante, Sergio Beccari, Giovanna Beccari, Maurizio Pascadopoli, Paola Gandini,
and Maria Francesca Sfondrini
Pavia, Italy

This case report presents the successful orthodontic repositioning of a transmigrated and lingually positioned
mandibular canine with conventional mechanics. Treatment began with the aim of creating space for the four
permanent canines that had not yet erupted. Cervical headgear, mesial slice, and extraction of the deciduous
teeth were executed, but only the right canines erupted; moreover, the mandibular left canine had become
lingually transmigrated. Multibracket therapy was performed with the orthodontic repositioning of both left ca-
nines in 2 steps. They were repositioned, and good alignment was obtained. To our knowledge, this is the first
case report describing the orthodontic repositioning of a lingually transmigrated canine with conventional double-
arch mechanics. This treatment was successful and without significant complications, even though this
approach can be challenging and time-consuming. (Am J Orthod Dentofacial Orthop 2023;163:272-84)

T
he orthodontic challenge related to maxillary and
mandibular canine impaction is commonly
encountered in clinical practice. However, trans-
migration is not as frequent and presents different treat-
ment challenges. Impaction is the failure of tooth
eruption 1 year after its physiological period. Transmi-
gration is the mesial pathway of eruption that can lead
the tooth to cross the midline.1 According to Javid’s defi-
nition, a transmigrated tooth crosses the midline with
more than half its total length.2
Canines fulfill important roles from both functional
and esthetic points of view,3 and their absence implies
significant orthodontic and surgical problems.4 The re-
ported incidence of impacted mandibular canines
ranged between 0.92% and 5.1%, compared with a ratio
of 1:20 for maxillary impaction. In contrast, the inci-
dence of transmigration ranged between 0.10% and
0.31%. Etiology includes hereditary factors, endocrine
dysfunctions, cancer, vestibular inclination of
From the Unit of Orthodontics and Pediatric Dentistry, Section of Dentistry,
Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University
of Pavia, Pavia, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Maurizio Pascadopoli, Unit of Orthodontics and Pae-
diatric Dentistry, Section of Dentistry, Department of Clinical, Surgical, Diag-
nostic and Paediatric Sciences, University of Pavia, Piazzale Golgi 2, Pavia
27100, Italy; e-mail, maurizio.pascadopoli01@universitadipavia.it.
Submitted, February 2021; revised and accepted, September 2021.
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2021.09.022
272
mandibular incisors, mandibular traumas in the area of
eruption of the canines, odontomes, cysts, retained
root stumps, and shape anomalies of adjacent teeth.5
Anatomic variations referred to as sella turcica bridging
have been associated with dental anomalies,6,7 with
buccally and palatally impacted maxillary canines being
the most common of these variations.8,9
Clinicians attempt to rescue mandibular canines
through various techniques if the adjacent incisors are
in a normal position and, if possible, try to create suffi-
cient space for their repositioning.10 If these conditions
are not present, other alternatives can be considered.11
The orthodontic repositioning of transmigrated mandib-
ular canines in the dental arch is difficult. Because of pa-
tient preference, surgical extraction is performed in most
situations. This may be one of the reasons that very few
patients treated with the surgical-orthodontic approach
are present in the literature.12-18
In this case report, we explain the procedures for the
orthodontic repositioning of a lingually positioned
transmigrated mandibular canine using conventional
mechanics.
DIAGNOSIS AND ETIOLOGY
A 13-year-old male patient was referred to our ortho-
dontics clinic by his general dentist. He was in good gen-
eral health, and his medical history was notable only for
a known allergy to dust mites. Extraoral photographs
showed a convex facial profile because of mandibular
Scribante et al
Fig 1. Initial facial and intraoral photographs.
deficiency (Fig 1). Based on the intraoral photographs
and the study models (Figs 1 and 2), the patient ap-
peared to have mixed dentition. A mild Class II Division
2 malocclusion was present, with a molar Class II rela-
tionship on the right side and a weak Class I on the
left side. A deep overbite was present, with a slight
malposition of maxillary incisors and small-sized maxil-
lary lateral incisors. The specific issue of hypoplastic in-
cisors made us consider a restorative approach for these
teeth after the orthodontic treatment to close spaces and
achieve the best esthetic result. The mandibular arch
presented mild crowding that allowed for the possibility
of taking advantage of leeway space (Figs 1 and 2).
The panoramic radiograph (Fig 3) revealed unfavor-
able eruption pathways for the permanent canines,
particularly the left canines. The lack of a prominent
labial bulge and the lateral cephalometric radiograph
suggested that the maxillary canines were in a palatal
position. Moreover, the lateral cephalometric radiograph
did not show the mandibular canine in the symphysis,
suggesting it was located lingually.
American Journal of Orthodontics and Dentofacial Orthopedics
273
Based on the lateral cephalometric radiograph and its
related tracing (Fig 3; Table), a skeletal Class II pattern
was noted (ANB, 5.1 ) with a correct position of the
maxilla (SNA, 80.9 ) and a retruded mandible (SNB,
75.8 ). We observed a good vertical relationship (SN-
GoGn, 30.5 ), with a normal divergence of bispinal
and mandibular planes (PP-GoGn, 17.4 ), orthognathic
residual growth pattern (Ar-Go-N, 49.6 ; N-Go-Gn,
67.2 ) and a slightly modified inclination of maxillary
and mandibular incisors (U1-PP, 102.7 ; IMPA 94.6 ).
Leonardi et al6 have suggested an association be-
tween sella turcica bridging and dental anomalies,
including the potential ectopic eruption of the perma-
nent teeth.7 Therefore, we performed a lateral skull
radiographic examination of sella turcica to evaluate
the presence of sella turcica bridging. Three points
were traced: dorsum sellae (DS), tuberculum sellae
(TS), and the farthest point on the inner wall of the sella
(PS). Two distances were calculated between these
points: the interclinoid distance (DS-TS) and the sella
diameter (TS-PS). The DS-TS was then compared with
February 2023  Vol 163  Issue 2
274
Fig 2. Initial study models.
the TS-PS. In this case report, the patient presented a
DS-TS (0.9 cm) that was less than three-quarters of the
TS-PS (1.35 cm) (Fig 4), suggesting a partial calcification
of the interclinoid ligament, known as bridging, con-
firming the unfavorable pathway of the eruption of the
permanent canines.8,9
Because of the presence of mixed dentition, we
decided to start the orthodontic therapy with phase 1,
which lasted only 9 months. After a brief intermission
of about 2 months, a decision was made to progress to
phase 2 of therapy when the patient presented perma-
nent dentition.
PHASE 1 TREATMENT OBJECTIVES
The treatment objectives of the first therapeutic
phase were as follows: (1) to promote the correct
pathway of eruption for maxillary and mandibular ca-
nines and their correct positioning in dental arches, (2)
to establish a correct Class I dental relationship, (3) to
establish a correct Class I skeletal relationship, and (4)
to improve the deep overbite.
PHASE 1 TREATMENT ALTERNATIVES
When teeth are suspected of following an incorrect
eruption pathway, preventive approaches to reestablish
the physiological eruption process are considered, thus
decreasing the risk of canine impaction or adjacent
root resorption of permanent teeth.
February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al
Deciduous tooth removal has been shown to be suc-
cessful in inducing eruption and, in some patients, even
horizontal movement of the cusp in a distal direction.19
In the maxillary arch, preventive treatment included us-
ing cervical headgear associated with extractions of the
maxillary first primary molars.
In the mandibular arch, extractions of deciduous ca-
nines and primary maxillary first molars, and the mesial
slice of the primary second molars were extracted.
PHASE 1 TREATMENT PROGRESS
In the maxillary arch, we used a cervical headgear
with an anterior biteplane, together with the extractions
of the maxillary first primary molars. In the mandibular
arch, the mesial slice of the primary second molars was
executed in addition to the extractions of deciduous
canines.
After approximately 9 months of therapy, we per-
formed a periapical radiograph of the permanent
mandibular canines (Fig 5, A), revealing a normal
pathway of eruption for the permanent mandibular right
canine, whereas there was a worsening in the eruption
pathway of the contralateral resulting in a horizontal
inclination.
We then performed a 3-dimensional imaging with
cone-beam computed tomography (CBCT), which high-
lighted the correct eruption pathways of permanent
right canines, whereas the maxillary left canine remained
palatally impacted, close to the root of the adjacent
Scribante et al
Fig 3. Initial orthogonal lateral cephalometric radiograph, cephalometric tracing, and panoramic radio-
graph.
lateral incisor that did not present signs of resorption
(Fig 5, B). The mandibular left canine was severely
transmigrated, lingually positioned, and covered
by cortical bone, with its crown in an intimate
relationship with the roots of mandibular left incisors
(Figs 5, C and D).
The advanced phase of permanent dentition and the
need for early intervention because of the worsening of
clinical conditions suggested the need to proceed with
phase 2 of the therapy to achieve a better bite, correct
management of spaces, provide anchorage for surgical
disimpaction and to allow for orthodontic repositioning
of the left canines.
PHASE 2 TREATMENT OBJECTIVES
Treatment objectives for phase 2 were as follows:
(1) to gain correct spaces for the traction of the
impacted canines, (2) to provide anchorage for surgical
disimpaction and to allow the orthodontic repositioning
of the left canines, (3) to establish a correct Class I dental
relationship, (4) to correct the excessive overbite, (6) to
improve facial esthetics, and (7) to maintain occlusal
stability.
American Journal of Orthodontics and Dentofacial Orthopedics
275
PHASE 2 TREATMENT ALTERNATIVES
Various treatment modalities are available for the
resolution of the clinical situation of the mandibular
transmigrated canines. These include surgical extrac-
tion, autotransplantation, observation, and surgical
exposure, followed by orthodontic repositioning.5
A surgical extraction is the most frequently
described option in the literature, especially in pa-
tients with severe inferior lack of space.13 In our pa-
tient, we gained the needed space with a mild
proclination of the mandibular incisors and by taking
advantage of the leeway space. Therefore, we could
consider alternatives to surgery because of the risks
associated with such a procedure. In addition, it
would have involved a high degree of complexity
because of the lingual position of the canine. Simi-
larly, we decided not to proceed with transalveolar
transplantation20 because of its complexity and the
potential long-term risks associated with this proced-
ure.21
To avoid further worsening the clinical situation,
including root resorption of mandibular incisors because
of the mandibular left canine’s crown, the option of
February 2023  Vol 163  Issue 2
276 Scribante et al

Table. Cephalometric measurements

Measurement Norm (mean 6 SD) Pretreatment Posttreatment
Skeletal pattern
SNA ( ) 82.0 6 2.0 80.9 84.2
SNB ( ) 80.0 6 2.0 75.8 81.9
ANB ( ) 2.0 6 2.0 5.1 2.3
Wits (mm) 0.0 6 2.0 0.7 1.4
SN-GoGn ( ) 32.0 6 5.0 30.5 23.5
PP-GoGn ( ) 20.0 6 5.0 17.4 15.1
Ar-Go-N ( ) 50.0 6 2.0 49.6 49.8
N-Go-Gn ( ) 70.0 6 3.0 67.2 66.7
Dental pattern
Interincisal angle ( ) 130.0 6 5.0 145.4 127.2
U1-PP ( ) 110.0 6 2.0 102.7 117.2
IMPA ( ) 93.0 6 1.0 94.6 100.5
Profile
Nasolabial angle ( ) 102.0 6 8.0 121.2 107.3
Facial angle ( ) 165.0 6 5.0 158.7 158.8
Upper lip (mm) - E plane 3.2 6 2.0 2.0 5.8
Lower lip (mm) - E plane 3.0 6 2.0 2.2 5.3
SD, standard deviation.

leaving the tooth in its ectopic position was abandoned,
and the option of orthodontic repositioning was taken
into consideration.11
PHASE 2 TREATMENT PROGRESS
The patient’s treatment was discussed with the pa-
tient’s parents explaining the complexity and length-
ening of therapy, and informed consent was obtained.
Because the patient had to undergo 2 surgical expo-
sures for the orthodontic repositioning procedures for
the left canines, orthodontic therapy initially started in
the maxillary arch.
The fixed appliance consisted of stainless steel
brackets, buccal convertible triple tubes on maxillary
first molar bands, buccal convertible double tubes on
mandibular first molar bands, and nonconvertible single
tubes with a distal notch on maxillary and mandibular
second molars bands (3M Unitek, Monrovia, Calif).
To place the mandibular fixed appliance, we bonded
bite raisings on the palatal surface of the maxillary
central incisors. This was possible thanks to anterior
retro-incisal mini molds for deep bites (Ormco Europe,
Amersfoort, BR, The Netherlands) that correctly posi-
tioned the brackets without occlusal interferences and
the early leveling of the inferior curve of Spee.
Fixed orthodontic treatment was managed with the
MBT technique up to the last maxillary 0.019 3
0.025-in stainless steel archwire and mandibular 0.018
3 0.025-in stainless steel archwire (3M Unitek). Open
coil nickel-titanium springs (3M Unitek) were inserted
to create space for the maxillary and mandibular left ca-
nines and mandibular right canines.
After gaining additional space, the surgical disimpac-
tion of the maxillary left canine could be executed. We
applied a transpalatal bar to provide more anchorage.
This was followed by cantilever mechanics using a
0.017 3 0.025-in beta-titanium archwire (3M Unitek)
placed inside the auxiliary tube of the first molar. The or-
thodontic repositioning for the maxillary left canine was
successful.
During his orthodontics treatment, the patient was
diagnosed with spina bifida occulta, a neural tube
defect.22 This further complicated his treatment course
as he could no longer attend his regular appointments,
resulting in the treatment duration lengthening. The pa-
tient underwent surgical interventions for his spina bi-
fida occulta, followed by physical therapy for leg
mobilization: the orthodontic treatment was interrup-
ted, but the appliance remained in place.
The patient was reexamined 4 months after his last
appointment: the surgical exposure of the mandibular
left canine was operated by an oral surgeon through a
mucoperiosteal flap, with a paramarginal initial incision.
After the ostectomy of the lingual cortical bone, a direct
button was bonded (3M Unitek), and an orthodontic
traction chain 0.012-in (Leone, Florence, Italy) with
traction eyelets was placed. The button was positioned
as close as possible to the canine’s coronal tip (Fig 6,
A), the flap was sutured, providing a complete covering
of the canine, and the metal ligature was connected,
without traction, to the bracket of the left first premolar.
Sutures were removed after 7 days, and the elastic
traction was applied with an elastic cotton thread
(Leone), adopting the double-arch technique for the

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Scribante et al 277

Fig 4. Linear dimensions of sella turcica.6-9 The patient presented an interclinoid distance (0.9 cm) that
was less than three-quarters of the TS-PS (1.35 cm), suggesting a partial calcification of the interclinoid
ligament and confirming the unfavorable pathway of eruption for the permanent canines.

Fig 5. Radiographic findings: A, Periapical radiograph of mandibular canines revealing a worsening in

the eruption pathway of the permanent mandibular left canine resulting in a horizontal inclination; B,
Transverse section of the maxillary arch. The maxillary left canine remained palatally impacted, close
to the root of the adjacent lateral incisor that did not present signs of resorption; C, Coronal anteropos-
terior section. The mandibular left canine was severely transmigrated, lingually positioned, and covered
by cortical bone; D, Transverse section of the mandibular arch showing the intimate relationship be-
tween mandibular left canine and the roots of mandibular left incisors.

orthodontic traction.23 To perform this technique, a
0.018-in Special Hard Drawn stainless steel Australian
auxiliary arch (AJ Wilcock Pty Ltd, Hay Mills, Birming-
ham, United Kingdom) was added, with a loop that al-
lowed the passage of the elastic traction through it,
positioned occlusally to the 0.018 3 0.025-in stainless
steel archwire and in the space between the mandibular
lateral incisor and the first premolar but closer to the first
premolar (Figs 6, B and 7). The loop’s distal position for
the initial phase of traction aimed to limit the risk of root
resorption of mandibular incisors. After a radiographic
evaluation (Fig 6, C), the button was repositioned in a
more coronal position, and the auxiliary arch was rede-
signed with the loop positioned at the center of the
space obtained for the mandibular left canine (Fig 6, D).
During this stage of therapy, space augmentation for
the mandibular left canine was progressively produced,
and the elastic traction was renewed every 2 weeks.
However, given the patient’s state of health, the patient
was unable to keep all his appointments, and therefore
the elastic traction was occasionally renewed less
frequently than every 2 weeks (Fig 6, E).
Afterward, a bracket was positioned, finalizing and
completing the case through a normal sequence of arch-
wires. We bonded the canine’s bracket without changing
the MBT prescription, keeping a torque value of 6 .
Because the impacted canine tipped buccally, this
bracket prescription effectively generated lingual crown
torque and buccal root movement with a 0.019 3
0.025-in nickel-titanium archwire. In a later stage, a

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
278 Scribante et al

Fig 6. Canine surgical exposure and orthodontic traction: A, surgical exposure and bonded button on
the mandibular left canine; B, Starting of orthodontic traction; C, Periapical radiograph suggesting the
need for the rebonding of the button in a more coronal position; D, Orthodontic traction after the rebond-
ing of the button; E, Stages of movement; F, Mandibular left canine present in the mandibular arch and
with its bracket.

0.019 3 0.025-in beta-titanium archwire was used, with
an additional torque bend (Fig 6, F). The canine was re-
positioned correctly, but a slight buccal tipping of the
crown remained; it was decided to avoid its further
correction because it would have prolonged the therapy.
The finishing phase was performed with maxillary
and mandibular 0.019 3 0.025-in multibraided stainless
steel archwires (3M Unitek).
TREATMENT RESULTS
The orthodontic repositioning of the left canines was
successful. At the end of the treatment, we obtained
optimal arches alignment with good alignment of the
curve of Spee and the achievement of molar and canine
Class I relationship (Figs 8 and 9).
Spaces distal to maxillary canines and lateral incisors
were due to a discrepancy in the Bolton analysis. Lateral
incisors and second premolars in the maxillary arch were
small-sized.
As already mentioned, the lingual root torque for the
mandibular left canine was not completely corrected.
The occlusal view showed the absence of gingival reces-
sion right after debonding; however, a gingival recession
could appear in long-term follow-up appointments.
Esthetic analysis showed an improvement in facial
profile and the achievement of a correct smile arc (Fig 8).
Radiographic evaluation revealed good radicular
parallelism and no sign of root resorption of maxillary
and mandibular incisors (Fig 10). The cephalometric
analysis highlighted the achievement of a skeletal Class
I (ANB, 2.3 ) and approximately correct divergence
values (SN-GoGn, 23.5 ; PP-GoGn, 15.1 ). The deep
overbite was corrected successfully; inevitably, an
acceptable proclination of maxillary and mandibular in-
cisors was obtained (U1-PP, 117.2 ; IMPA, 100.2 ) (Fig
11).
To avoid relapses, a maxillary clear plastic retainer
fabricated with a 1 mm thick sheet was given to the pa-
tient, whereas a splint with a 0.8 mm steel wire (Rema-
nium lingual retainer; Dentaurum, Ispringen, Germany)
was placed and bonded only on the lingual surfaces of
mandibular canines.
The patient’s parents decided to postpone the restor-
ative reconstructions for the small-sized maxillary lateral
incisors.
The entire orthodontic treatment lasted 38 months
and was highly influenced by the state of the general
health of the patient. Because of the patient’s need for
surgical interventions with subsequent periods of phys-
ical therapy, his compliance was inevitably low.
DISCUSSION
Our patient presented for the first time in the later
mixed dentition stage, with the persistence of deciduous
canines. The permanent canines were impacted, as the
pretreatment panoramic radiograph shows. In complex

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Scribante et al
Fig 7. Schematic illustration of the double-arch tech-
nique: the elastic traction (red), the round Australian arch-
wire 0.018-in (green), the stainless steel archwire 0.018 3
0.025-in (blue), and the open coil nickel-titanium springs
(yellow).
patients, such as ours, early diagnosis could prevent the
worsening of the clinical situation because the teeth can
be intercepted in a better position for orthodontic repo-
sitioning, although it involves time-consuming
procedures.24 We used cervical headgear to correct the
Class II relationship and improve maxillary canines’
inclination25,26: the right canine erupted in the
following stages of therapy, whereas the left canine
needed surgical exposure and orthodontic repositioning.
The same scenario occurred in the mandibular arch.
The mandibular left canine became severely transmi-
grated and underwent surgical exposure followed by or-
thodontic repositioning, whereas the right canine was
able to erupt. The spontaneous eruption of the mandib-
ular right canine was probably a result of the extraction
of both the corresponding deciduous tooth and the first
primary molar, in addition to a 1.5 mm mesial slice of the
primary second molar: these procedures allowed for the
creation of more space and the removal of a potential
mechanical obstacle.3
Among the various causes of transmigration,5,11
retention of persistent deciduous canines occurred in
both arches at a later stage of growth of our patient.
Moreover, smaller maxillary lateral incisors and inade-
quate space in the mandible were present; nevertheless,
the right canines erupted without specific interventions.
Although there was a mechanical reason for canine
retention in this patient, a genetic etiology could have
played a role considering that all the permanent canines
were displaced in the pretreatment stage. As suggested
in previous studies,6-9 variations of the anatomic shape
of sella turcica can be related to dental anomalies.
Indeed, Scribante et al8 found that partial calcifications
were more related to dental anomalies, particularly
buccal and palatal impaction of maxillary canines,
compared with total calcification. Our patient had
American Journal of Orthodontics and Dentofacial Orthopedics
279
evidence of partial calcification, and therefore an early
diagnosis could have been considered thanks to the
analysis of the shape of the sella turcica.
Regarding the possible role of malocclusions in the
transmigration of the mandibular canine, some
authors27 found that factors like Class II dental pattern
with a deep overbite, deep curve of Spee, excess tooth
material, and increased lower anterior facial height
may be predisposing factors. We found a Class II dental
pattern with a deep overbite and a slightly increased
lower anterior facial height in our patient. Others have
found that a Class I dental pattern was more frequent
in canine transmigration.28
To compare similar clinical patients and decide the
best approach to the problem, we used the 5-type Mup-
parapu classification29 to classify the various positions
that transmigrated canines can assume: our patient cor-
responds to type 1 in the Mupparapu classification. The
mandibular left canine was mesioangular positioned
across the midline within the jaw bone, lingually to ante-
rior teeth, and with its crown portion that crosses the
midline. Several studies have found that Mupparapu’s
type 1 was the most frequently diagnosed type among
canine transmigrations.28,30-32
The spatial position of the canines and their probabil-
ity to cross the midline can also be evaluated through the
angle between the canine’s axial inclination and the
midsagittal plane.20 If this angle ranges from 25 to
30 , the canine is displaced, but it does not cross the
midline. The canine will cross the midline if the angle
is from 50 to 90 . Finally, there is an overlapping
area, within the range of 30 -50 , in which the canine
can cross the midline or not. The pretreatment pano-
ramic radiograph (Fig 3, C) shows that this angle’s value
was 13.41 for the mandibular right canine and 48.52
for the left canine. The second value signaled possible
transmigration. The periapical radiograph (Fig 5, A)
and the CBCT frontal section (Fig 5, B) executed after
9 months confirmed the evolving pathway of the
mandibular left canine that crossed the midline toward
the contralateral side. CBCT is also more accurate in de-
tecting root resorption of adjacent teeth.4,33 Following
the clinical rationale of Cavuoti et al,14 we preferred to
perform the 3-dimensional examination once, after the
beginning of the fixed orthodontic treatment, to
monitor the development of the clinical situation. More-
over, lingual position and older age are risk factors for
the impacted canine transmigration.1
Although there is an abundance of literature explain-
ing detailed procedures for the orthodontic reposition-
ing of labial mandibular impacted or transmigrated
canines,14-18 there is a paucity of literature on patients
addressing canine’s lingual position. Most articles
February 2023  Vol 163  Issue 2
280
Fig 8. Final facial and intraoral photographs.
report only on the prevalence of lingual positioning of
transmigrated canines: Karabas et al34 and Bertl et al35
reported a prevalence of 8.6% and 8.5%, respectively,
whereas Koç et al1 a prevalence as high as 51.4%. Only
1 article noted that they successfully treated a lingually
oriented canine with the insertion of a temporary skel-
etal anchorage device, but the steps of the orthodontic
treatment were missing.12
We adopted the double-arch technique (Fig 7),23 so-
called for using 2 archwires, for the orthodontic traction
of the mandibular transmigrated canine. The stabiliza-
tion archwire is a stainless steel rectangular wire inserted
at first and ligated to the brackets, only to be removed
after the canine’s eruption. Its purposes are anchorage,
maintenance of the space for the canine, and mainte-
nance of the arch form. The traction archwire is a round
Australian archwire 0.018-in, applied over the rectan-
gular archwire and with a step-down bend in the space
for the canine’s eruption. The step-down bend is de-
signed from the distal surface of the lateral incisor to
the mesial surface of the first premolar. It presents a
February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al
directional eyelet that guides the traction force depend-
ing on its position.
At first, the direction of the orthodontic force was
distal to limit the stress in that region and avoid the
risk of resorption of the roots of the adjacent teeth
because of the intimate position of the crown of the
canine36; the incidence of this occurrence is estimated
to be 7.3% and is more likely if the canine is lingually
impacted.35 Subsequently, the eyelet was moved more
centrally on the alveolar process of the canine. Force
traction did not exceed $60 g, as suggested in the liter-
ature,37 and the repositioning was successful, with a
slight lingual inclination of the tooth that was decided
not to correct beyond to avoid the lengthening of the
treatment. We evaluated using a cantilever for the trac-
tion of the transmigrated canine, but the presence of an
excessive overbite caused occlusal interferences. An
alternative could have been to bend the hole for the
elastic thread directly on the rectangular wire instead
of the 0.018-in auxiliary Australian wire. In our patient,
the auxiliary arch allowed control of the force direction,
Scribante et al
Fig 9. Final study models.
whereas the stabilization arch maintained the arch form
during traction. Light forces were applied to the traction
to control the proclination of the mandibular incisors.
The lack of a stronger anchorage inevitably caused
the proclination of mandibular incisors; appliances for
the reinforcement of the anchorage, such as the lingual
arch22,38 and the lip bumper,39 have been proposed, but
the former could not be applied because of the presence
of the transmigrated canine, whereas the latter could
have reduced the already low compliance of the patient,
which was the reason why the possibility of inserting a
temporary skeletal anchorage device, as done by Sinko
et al,12 was excluded. Herein, miniscrews were used as
support for the orthodontic treatment, successfully re-
positioning the transmigrated canine in 3 out of 4 pa-
tients. Better results may have been obtained if the
patient were treated with a skeletal anchorage provided
by the insertion of a miniscrew. However, we preferred to
adopt conventional mechanics to avoid adding a second
step of oral surgery.
The patient suffered from spina bifida occulta, a
neural tube defect in which there is a failure of neural
tube closure during the first month in utero. This spina
bifida is characterized by no herniation of central ner-
vous system contents, rare symptoms, and complica-
tions, and is usually found incidentally.22 There are
several implications of this diagnosis in dentistry: diffi-
culties in sitting in the dental chair, limited jaw opening,
a higher risk of infective endocarditis during invasive
American Journal of Orthodontics and Dentofacial Orthopedics
281
procedures, more susceptibility to dental caries, poor
oral hygiene, and a latex allergy prevalence of 28%-
67%.40 Given the findings related to sella turcica that
were observed on the lateral cephalometric radiograph,
a diagnosis of spina bifida could have been made before
the orthodontic treatment. Indeed, the detection of sella
bridging is expressly related to myelomeningocele, the
most common and severe form of spina bifida occulta.22
An early diagnosis could have modified the treatment
approach and changed the therapy duration: the
surgical intervention and the pathology inevitably
lengthened the orthodontic treatment, already in itself
long-lasting and complex. Compliance was inevitably
affected, which in turn affected the orthodontic treat-
ment. Proper oral hygiene was hard to achieve, and
cooperation with orthodontic elastics was very low.
Further complicating the situation, the patient had dif-
ficulty sitting in the dental chair after his surgical inter-
ventions. The other complications related to spina bifida
did not occur in our patient, likely because of a milder
type of disease in his case.
SUMMARY AND CONCLUSIONS
Lingual transmigration of mandibular canines is an
uncommon occurrence that clinicians should be ready
to address when patients present to their clinic. Early
diagnosis and intervention in patients with an anoma-
lous eruption pathway of permanent canines can be
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282 Scribante et al

Fig 10. Final orthogonal lateral cephalometric radiograph, cephalometric tracing, and panoramic
radiograph.

Fig 11. Cephalometric superimpositions between initial (black) and final (red) tracings.

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Scribante et al
decisive. Conventional mechanics for the orthodontic re-
positioning of lingually transmigrated mandibular ca-
nines can result in successful outcomes without
significant complications, even though it can be chal-
lenging and time-consuming.
ACKNOWLEDGMENTS
The authors would like to thank Filiberto Cricr
ı (Cair-
oli College) for the free-hand drawing of Figure 7.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2021.09.022.
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