Diagnosis of canine impaction.

1. DIAGNOSIS OF CANINE IMPACTION
Thabassum Parakkal

2. CONTENTS
• INTRODUCTION
• ERUPTION OF CANINE
• FACTORS GOVERNING ERUPTION OF CANINE
• IMPACTION
• INCIDENCE
• CLASSIFICATION
2

3. • THEORIES OF IMPACTION
• SEQUALAE OF IMPACTED TEETH
• DIAGNOSIS
• PROGNOSIS
• CONCLUSION
• REFERENCES
3

4. INTRODUCTION
4

5. ERUPTION OF CANINE
• DEVELOPMENT OF CANINE :
4-5 months of age between the roots of deciduous first molar
5
Holly Broadbent. Ontogenic development of occlusion AO 1941

6. •CALCIFICATION :
12 months
6
Holly Broadbent. Ontogenic development of occlusion AO 1941

7. 7
Holly Broadbent. Ontogenic development of occlusion AO 1941

8. 8
Holly Broadbent. Ontogenic development of occlusion AO 1941

9. • FINAL PHASE OF ERUPTION
Canine drive their way between the first premolars,forcing these teeth to become more upright.
9
Holly Broadbent. Ontogenic development of occlusion AO 1941

10. • Posterior movement occurred between 7and 13 years.
• Vertical movement occurred between5 and 13 years.
• Lateral movement tend to be in a palataldirectionup to 2 years before eruption followed by significantbuccal movement in the year
before eruption.
• Data are given for eruption in three planes.
• Maxillarycanine travel almost 22mm from their positionat the age of 5 yrs to their positionat 15 yrs
10
Coulter, J., & Richardson, A. (1997). Normal eruption of the maxillary canine
quantified in three dimensions. European Journal of Orthodontics, 19(2), 171–183.

11. FACTORS GOVERNING ERUPTION OF
CANINE
• Position of tooth bud in bony crypt.
• Path of eruption.
• Shape and position
• Amount of space available for canines in the arch.
11

12. IMPACTION
• Canine impaction : Maxillary > Mandibular
• Maxillary canine impaction palatal canine impaction is more common than buccal canine
impaction.( Jacoby, H. (1983)
• Asians - buccally impacted canines more frequently than from palatally impacted canines.
Females > males.( Oliver ;1989 )
12

13. INCIDENCE
• Dachi and Howell (1961) – 0.92%
• Thilander and Myrberg (1973) – 7-13 yr old- 2.2%.
• Ericson and Kurol (1986) – 1.7%.
• Females- 1.17%, Males – 0.51%
• Bilateral impaction – 8%
• Mandibular canine impaction – 0.35%.
13
Bishara, S. E., & Ortho., D. (1992). Impacted maxillary canines: A review. American Journal of
Orthodontics and Dentofacial Orthopedics, 101(2), 159–171.

14. Prevalence of Impacted Teeth in Indian population
MANDIBULAR 3RD
MOLARS
MAXILLARY
3RD MOLARS
MAXILLARY
CANINES MANDIBULAR
PREMOLARS
MANDIBULAR
CANINES
MAXILLARY
PREMOLARS
MAXILLARY
CENTRAL
INCISORS
14

15. INDICATORS
• Lack of bulge in the buccal vestibule after 10yrs of age.
• Presence of bulge in the palate.
• Contralateral canine has erupted and there has been gap for more than 6 months since its
eruption.
• Retained deciduous canine
• Severe crowding.
• Missing lateral incisors.
• Unusual rotation of lateral incisor
15

16. CLASSIFICATION
IMPACTION
MAXILLA MANDIBLE
BUCCAL PALATAL BUCCAL LINGUAL
16

17. ARCHER’S CLASSIFICATION
17
Archer W.H. Oral Surgery. Philadelphia, Pa, USA: The W.B. Sounders company 1966

18. 18
Archer W.H. Oral Surgery. Philadelphia, Pa, USA: The W.B. Sounders company 1966

19. FIELD AND ACKERMANN 1935
• Horizontal (with respect to arch)
- Palatal
- Mid- alveolar
- Labial
• Vertical ( with respect to apex)
- Above
- Below
19
Mulick, J. F. (1979). jco / interviews on Impacted Canines. (December).

20. Yavuz MS, Aras MH, Büyükkurt MC, Tozoglu S. Impacted Mandibular Canines. J
Contemp Dent Pract 2007 November; (8)7:078-085.
20

21. Michael Kalavritinos .Incidence of incisor root resorption associated with the position of the impacted maxillary canines: A
conebeam computed tomographic study Am J Orthod Dentofacial Orthop 2020;157:73-9
21

22. ETIOLOGY 23
Bishara SE: Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop 101: 159-171, 1992

23. • Of all the local factors , arch length deficiency is believed to be the most common cause of labially impacted
canines.
• Jacoby(1983) observed that,
85% of palatally impacted canines - Had sufficient space for eruption
17% of labially impacted canines - Had sufficient space to erupt in the arch.
23
Hamada, Y., Timothius, C. J. C., Shin, D., & John, V. (2019). Canine impaction – A review of the
prevalence, etiology, diagnosis and treatment. Seminars in Orthodontics, 25(2), 117–123.

24. Bishara (1976) and associates summarized Moyer’s theory that impaction is
caused by:
1. Primary causes:
A. Rate of root resorption of deciduous teeth
B. Trauma of the deciduous tooth bud.
C. Disturbances in tooth eruption sequence.
D. Availability of space in the arch.
E. Rotation of tooth buds.
F. Premature root closure.
G. Canine eruption into the cleft area in persons with cleft palate
24
Jacoby, H. (1983). The etiology of maxillary canine impactions. American Journal of Orthodontics, 84(2),
125–132.
2.Secondary causes:
A. Abnormal muscle pressure.
B . Febrile diseases.
C. Endocrine disturbances.
D. Vitamin D deficiency.

25. 25
Becker, A., & Chaushu, S. (2015). Etiology of maxillary canine impaction: A review.
American Journal of Orthodontics and Dentofacial Orthopedics, 148(4), 557–567.

26. THEORIES OF CANINE IMPACTION
Mc Bridge concept :
• Canine is formed high in the anterior wall at antrum, below the floor of orbit.
• Tooth travel from floor of orbit to oral cavity hence had greater chances of “losing its path”.
26

27. Becker (1984) :
• Two processes for palatal displacement of maxillary cuspid:
1. Developmental - absence of guidance of lateral incisor
2. Tooth moving down into a narrower part of alveolar process
27

28. Vonder Heydt concept :
• Total arch length of permanent teeth initially established at the time of eruption of 1st permanent molars.
• Canine is larger and later erupting.
28

29. Peck and peck concept (Genetic Theory):
• Palatally impacted canine is an inherited trait.
• Bilaterally occurring phenomenon (17 %)
• Females affected more than males (1 : 3.2)
• Familial occurrence
• So they concluded palatally impacted canine as dental anomaly
having GENETIC ORIGIN.
29

30. INCONSISTENCIES OF THE GENETIC THEORY OF CANINE IMPACTION :
• If canine impaction were under hereditary control, it is reasonable to expect bilateral canine impaction in
most patients.
• From the epidemiologic information gleaned from the many studies in the orthodontic literature, the findings
indicate 60% to 75%preponderance of unilateral canine impaction
30
Becker, A., & Chaushu, S. (2015). Etiology of maxillary canine impaction: A review. American
Journal of Orthodontics and Dentofacial Orthopedics, 148(4), 557–567.

31. Guidance theory - Miller:
1. Normal eruption - Adopts Broadbent’s guidance for the canine
31

32. • 2. First-stage impaction. Absence of guidance at a critical time in the normal development of the
permanent canine . 32

33. 3.First-stage impaction with secondary correction.
33

34. 4. Second-stage impaction. 34

35. 5. Second-stage impaction with secondary correction.
• Extraction of an over-retained deciduous canine, or even the anomalous lateral incisor itself, may often
lead to spontaneous eruption of the impacted tooth.
35

36. SEQUELAE OF CANINE IMPACTION
Labial or lingual malpositioning of impacted tooth
Migration of neighboring teeth and loss of arch length
Internal resorption or external resorption of impacted or neighbouring tooth
Dentigerous cyst formation
Infection particularly with palatal impaction and referred pain.
36

37. RISK FACTORS ASSOCIATED
• Malocclusion and loss of arch length
• Dentigerous cyst or odontogenic tumors
• Root resorption of adjacent teeth
• Maleruption of adjacent teeth
• Migration or loss of neighbouring teeth
37

38. DIAGNOSIS
• Inspection
• Palpation
• Radiographs
38

39. INSPECTION 39

40. PALPATION 40

41. RADIOGRAPHIC EVALUATION
RADIOGRAPHS
PERIAPICAL OCCLUSAL EXTRA-ORAL
MAXILLARY ARCH MANDIBULAR ARCH OPG LATERAL PA
VIEW
CEPH
41

42. 3 D LOCALIZATION
PARALLAX METHOD CBCT
42

43. PERIAPICAL FILMS 43

44. SLOB RULE 44

45. 45
Vertical parallax : 76 % cases were successfully detected.
Magnification method :66 % cases were successfully detected with this
method.
Using both methods 90 % cases can be detected.
(Radiographic localization of impacted maxillary canines: comparisons of methods by carol mason
et al EJO 2001 23 ; 25-34)

46. EJO 2003
Concluded that localization of ectopic maxillary canines was
significantly more successful with horizontal parallax than with vertical
parallax. But both radiographic techniques were poor at localizing buccal
EMC (success rate is only 63%).
46

47. OCCLUSAL RADIOGRAPHS 47

48. 48

49. DISADVANTAGES:
A.Needs a long exposure; patient movement can ruin the film.
B.No information regarding the relative height of the object in the alveolus.
C.Poor detail due to superimposition of various anatomic structures in the
area.
D.Absorbed dose of radiation to various radiosensitive organs: Brain,
pituitary, salivary glands, thyroid gland, and eye lens.
49

50. EXTRA ORAL
• Lateral cephalogram.
• P A view.
• OPG
• CT
50

51. LATERAL CEPHALOGRAM
51

52. LATERAL CEPHALOGRAM PA CEPHALOGRAM OPG
•Antero-
posterior
•Vertical
location
•Vertical location
•Transverse
localization
•A-P localization
•Transverse
localization
By combining the results of any two of these films ,
three dimensional localization may be determined
52

53. CT SCAN
53

54. CBCT 54
A newly developed dental volumetric imaging device, uses cone-beam
radiation to gather similar information in the working range of dental
radiography.
3D volumetric imaging of impacted canines can show the following:
Presence or absence of the canine,
Size of the follicle,
Inclination of the long axis of the tooth, relative buccal and palatal positions,
Amount of the bone covering the tooth

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59. 59

60. DIAGNOSTIC METHODS 60

61. SECTOR METHOD – ERICSON AND KUROL
61

62. 62

63. 63
The values that indicate a favourable canine impaction are as follows –
Alpha angle - ≤ 35±13°
Distance – 15±4mm
Sector – 3
Values beyond this range indicate an unfavourable impaction.
Michele Nieri, Aldo Crescini, Roberto Rotundo, Tiziano Baccetti, Pierpaolo Cortellini, and
Giovan Paolo Pini Prato. Factors affecting the clinical approach to impacted maxillary
canines: A Bayesian network analysis. (Am J Orthod Dentofacial Orthop 2010;137:755-62)

64. 64

65. 65

66. KPG INDEX
66

67.  Prognosis is Difficult
67

68. 68
Alqerban A, Jacobs R, Fieuws S, Willems G. Radiographic predictors for maxillary canine
impaction. Am J Orthod Dentofacial Orthop. 2015 Mar;147(3):345-54.

69. 69
Alqerban A, Jacobs R, Fieuws S, Willems G. Radiographic predictors for maxillary canine
impaction. Am J Orthod Dentofacial Orthop. 2015 Mar;147(3):345-54.

70. 70
Alqerban A, Jacobs R, Fieuws S, Willems G. Radiographic predictors for maxillary canine
impaction. Am J Orthod Dentofacial Orthop. 2015 Mar;147(3):345-54.

71. 71

72. 72
The CBCT-MCI guide was proven to be an excellent and simple tool to
diagnose the severity of MCI and predict the best method of intervention.

73. 73

74. 74

75. RADIOGRAPHIC INTERPRETATION
 NATURE OF COVERING TISSUES :
1. SOFT TISSUE IMPACTION
2. PARTIAL BONY IMPACTION
3. FULLY BONY IMPACTION
 CROWN SIZE
 ROOT CONFIGURATION:-
1) NUMBER OF ROOTS
2) LENGTH OF ROOTS
3) SIZE OF ROOTS
4) CURVATURE OF ROOT
5) DEVELOPMENT OF ROOT
6) INTERNAL & EXTERNAL RESORPTION
 BONE TEXTURE & DENSITY
 SIZE OF FOLLICULAR SAC
 RELATIONSHIP TO VITAL ORGANS :
- MENTAL NERVE (Mandible)
- MAXILLARY SINUS (Maxilla)
75

76. POINTS TO BE NOTED FROM THE
RADIOGRAPH:
• Labio palatal position
• Direction of long-axis of unerupted canine and relationship to adjacent tooth.
• Size, shape and root pattern of canine.
• Position of its crown and root apex relative to the adjacent teeth.
• Presence of associated cyst, odontoma or supernumerary teeth.
• Curvature of impacted tooth.
76

77. PROGNOSIS FOR IMPACTED CANINE
77

78. INDICATIONS FOR EXTRACTION OF IMPACTED
TEETH
• Changed position of adjacent teeth
• Resorption of roots of adjacent teeth.
• Cyst formation.
• Cleft palate
• Neurologic symptoms.
78

79. CONTRAINDICATIONS
• Compromised medical status
• Probable excessive damage to adjacent structures.
79

80. WHEN TO EXTRACT ?
• If it is ankylosed and cannot be transplanted.
• If it is undergoing external and internal resorption.
• If its root is severely dilacerated.
• If the impaction is severe.
• If there are pathologic changes.
80

81. TREATMENT ALTERNATIVES
• No treatment if the patient does not desire it.
• Auto transplantation of the canine.
• Extraction and move first premolar.
• Extraction of canine and posterior segmental osteotomy.
• Prosthetic replacement of canine.
• Surgical exposure of canine.
81

82. CONCLUSION
• Management of the impacted canine is one of the greatest challenge for
orthodontist.
• Success of the treatment depends upon patient cooperation, Age of patient, Proper
diagnosis, Level of canine impaction, Inclination and Depth of impaction etc.
• With the advent of 3D diagnosis and various other diagnostic methods we can now
easily predict the prognosis and treatment time too.
82

83. REFERENCES
• Holly Broadbent. Ontogenic development of occlusion AO 1941
• Coulter, J., & Richardson, A. (1997). Normal eruption of the maxillary canine quantified in
three dimensions. European Journal of Orthodontics, 19(2), 171–183.
• Bishara, S. E., & Ortho., D. (1992). Impacted maxillary canines: A review. American Journal
of Orthodontics and Dentofacial Orthopedics, 101(2), 159–171.
• Archer W.H. Oral Surgery. Philadelphia, Pa, USA: The W.B. Sounders company 1966
• Mulick, J. F. (1979). jco / interviews on Impacted Canines. (December).
83

84. • Alqerban, A., Jacobs, R., Fieuws, S., & Willems, G. (2011). Comparison of two cone beam
computed tomographic systems versus panoramic imaging for localization of impacted
maxillary canines and detection of root resorption. European Journal of Orthodontics, 33(1),
93–102.
• Armstrong, C., Johnston, C., Burden, D., & Stevenson, M. (2003). Localizing ectopic
maxillary canines - Horizontal or vertical parallax? European Journal of Orthodontics, 25(6),
585–589.
• Jacoby, H. (1983). The etiology of maxillary canine impactions. American Journal of
Orthodontics, 84(2), 125–132.
84

85. • Becker, A., & Chaushu, S. (2015). Etiology of maxillary canine impaction: A review. American
Journal of Orthodontics and Dentofacial Orthopedics, 148(4), 557–567.
• Padisar, P., Tofangchiha, M., Salari, B., & Oveisi, S. (2020). Comparison of Three-Dimensional
and Conventional Orthodontic Imaging Modalities for Localization of Impacted Maxillary
Canines in Patients With Alveolar Cleft. Cleft Palate-Craniofacial Journal.
• Van Elslande, D., Heo, G., Flores-Mir, C., Carey, J., & Major, P. W. (2010). Accuracy of
mesiodistal root angulation projected by cone-beam computed tomographic panoramic-like
images. American Journal of Orthodontics and Dentofacial Orthopedics, 137(4 SUPPL.), S94–
S99.
85

86. • Hamada, Y., Timothius, C. J. C., Shin, D., & John, V. (2019). Canine impaction – A review of the
prevalence, etiology, diagnosis and treatment. Seminars in Orthodontics, 25(2), 117–123.
• Sosars, P., Jakobsone, G., Neimane, L., & Mukans, M. (2020). Comparative analysis of panoramic
radiography and cone-beam computed tomography in treatment planning of palatally displaced canines.
American Journal of Orthodontics and Dentofacial Orthopedics, 157(5), 719–727.
• Alhummayani FM, Mustafa ZA. A new guide using CBCT to identify the severity of maxillary canine
impaction and predict the best method of intervention. J Orthodont Sci 2021;10:3.
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