Resorption of maxillary lateral incisors caused by

ectopic eruption of the canines

A clinical and radiographic analysis of predisposing factors

Sune Ericson, DDS, Odont. Dr.,* and Jiiri Kurol, DDS, Odont. Dr.**
JSnkiiping, Sweden

Factors predisposing to resorption of adjacent permanent lateral incisors caused by ectopic eruption
of maxillary canines were evaluated. The subjects consisted of two groups: one with 40 lateral
incisors with resorption caused by ectopic eruption and a control group of 118 ectopic eruption cases
with no lateral incisor resorption. The mean age of the children in the two groups differed by only 0.7
of a year and ranged from 10.0 to 15.0 years, covering the normal eruption period of the maxillary
canine. Resorption of lateral incisors was three times as common in girls as in boys. The resorption
cases showed a more advanced dental development, a more medial canine position,in the dental
arch, and a slightly more mesial horizontal path of eruption (an average of 100) than that of the
control cases. Factors such as the width of the dental follicle and proclination or distal tilting of the
lateral incisor showed no correlation to the resorption. Potential resorption cases are always those in
which the canine cusp in periapical and panoramic films is positioned medially to the midline of the
lateral incisor. Such situations should be carefully investigated with polytomography if necessary.
The risk of resorption also will increase with a more mesial horizontal path of eruption. From 10
years of age or younger, annual clinical examination by palpation of the canine eruption path is
recommended. This clinical examination should be supplemented with a stepwise extended
radiographic procedure in cases in which ectopic eruption of the maxillary canines is suspected. (AM
J ORTHOD DENTOFAC ORTHOP 1988:94:503-l 3.)

T he permanent maxillary canine is fre-

quently misplaced in relation to other teeth in the max-
illa. The prevalence of noneruption and ectopic eruption
of this tooth has been reported to be 0.9% to 2.0% in
samples not previously selected for orthodontic treat-
ment., The canine is most frequently found palatal to
the lateral incisor and buccally in only about 15% of
cases,2-4
Ectopic eruption of maxillary canines may lead to
impaction and/or resorption of neighboring permanent
teeth.*, However, in most studies of the eruption of
the maxillary canines, the latter complication is sparsely
reported. This might give the impression that resorption
caused by the eruption of the maxillary canine is rare
and of minor clinical importance, however unfortunate
in the individual case. The lesions often are difficult to
diagnose with ordinary radiographic techniques because
most of the resorptions are located palatally or buccally
in the middle third of the root of the adjacent lateral
incisor. Often they are concealed by overlapping of the
canine in the periapical radiographs.
In a recent epidemiologic study of maxillary canine
From the Departments of Maxilla-Facial Radiology* and Orthodontics.**
Institute for Postgraduate Dental Education.
eruption in which uninterpretable areas caused by over-
lapping on the intraoral radiographs were examined by
polytomography, it was found that resorption of lateral
incisors occurred in 12% of cases after ectopic eruption
of maxillary canines, suggesting a total prevalence of
0.7% for resorbed lateral incisors in the lo- to 13-year
age group.
During eruption of the maxillary canines, these teeth
are in very close contact with the lateral incisors due
to the anatomy in this region, and it has been shown
in radiographs that the lamina dura often is missing.,6
Furthermore it is believed that in situations of resorp-
tion, there must be close contact between the canine
and lateral incisor, rather than mediation of the resorp-
tion by swelling of the dental follicle.. The importance
of the dental follicle in the tooth eruption process has
been shown in animal experiments. However, it is not
clear what the predisposing causative factors in this
incisor resorption process are and in what positions and
situations an ectopically erupting or misplaced canine
is liable to resorb the adjacent teeth.
This investigation was undertaken in an attempt to
elucidate the role of various causative factors in the
The resorption of lateral incisors caused by ectopic eruption
of maxillary canines. A further aim was to evaluate the
503
504 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Fig. 1. Records of female subject, aged 10 years 10 months. Lateral (A and B) and occlusal (C and
D) views of the dentition and dental arches show crowding and lack of space. Extraction of first premolars
was indicated and the patient was referred for orthodontic treatment. Note the buccal position of the
maxillary canines. E, Axial-vertex intraoral radiograph at 11 years 3 months of age shows the position
of the maxillary canines relative to the dental arch. In the Orthopantomograph F, the medial position
of the canine crowns and degree of mesial path of eruption are seen. In the periapical dental films (G
and H), an overlapping of the canine over the lateral incisor is seen together with an unbroken
mesiodistal root contour. The lamina dura is missing. Because of this and the close relation between
the canine and lateral incisor as seen in E, further radiographic investigation is indicated. (Which one
of the lateral incisors is resorbed?)

strength of various possible predisposing factors sin- eruption. The two groups were investigated in an iden-
gularly associated with the resorption of lateral incisors tical manner, both clinically and radiographically. In no
by comparing resorption cases with nonresorption cases case had the canine erupted into the oral cavity. The
after ectopic eruption of the maxillary canine. primary canine was missing in 30% of the subjects.

SUBJECTS Resorption group

The material for this study was derived from two
groups: a group with resorption of the maxillary per-
manent lateral incisor associated with ectopic eruption
of the maxillary canine and a control group in whom
the incisor was not resorbed because of the ectopic
This group comprised 40 consecutively collected
cases with resorbed lateral incisors with varying degrees
of resorption. No evidence of traumatic injuries to the
incisors was found. A detailed presentation of the lo-
cation and extent of resorption on the lateral incisors
Volume 94 Resorption of mcrrilla~ incisors 505
Number 6

Fig. 1 (Contd). The sagittal polytomograms (I and J) show that the girls right lateral incisor is buccally
in close relation to the canine crown and a resorption cavity ~&WOWS) is seen extending into the pulp.
On the left side, there is close contact between the lateral incisor root and canine crown but without
resorption. The girl showed a lack of interest and was reluctant to wear a visible fixed orthodontic
appliance. In K, the extracted lateral incisor on the right side shows a buccal resorption in the middle
third of the root and the radiograph L shows the full extent of buccal root resorpQon. Note the conformity
of information between the polytomogram (I) and the radiograph (L). For reasons of symmetry, both
lateral incisors were extracted, and in M and N the clinical and radiographic frontal views of both the
resorbed and normal lateral incisors are seen. The intraoral photograph (0) of the maxillary dental
arch shows the result 8 months after extraction at 12 years 0 months of age.

has been given previously. In 34 of the 40 lateral in-
cisors (85%), the erupting canine was found in an ec-
topic position lingually, distolingually, or buccally to
the resorbed incisor root. In six cases the canine position
was distal to the lateral incisor root. In 45% of the
lateral incisors, the resorption extended into the pulp.
Control group
The material for the control group was collected
from material presented earlie?.6.o in a series of studies
on normal and ectopic canine eruption. This group con-
sisted of 118 cases of nonerupted maxillary canines with
an ectopic path of eruption, but without causing re-
sorption of the lateral incisor roots. From the radio-
graphs it could be seen that the two materials were very
similar and comparable with regard to the position of
the canine crown relative to the adjacent teeth in the
dental arch. In 83% of cases, the canine crowns showed
lingual, distolingual, or buccal positions relative to the
incisor root. Buccal positions were noted for 15% of
the canines (as compared with 18% in the resorption
group).
Age
The age of the subjects ranged from 10.1 to 14.9
years in the resorption group and from 10.0 to 15 .O
years in the control group. The mean age in the re-
sorption group was 12.1 + 1.2 years; in the control
group, the mean age was 11.3 t 1.O years. This minor
difference in age (mean 0.7 years) between the two
groups was not statistically significant.
METHODS
Radiographic examination
The radiographic examination was performed ac-
cording to defined criteria and an earlier described step-
wise procedure.. In addition to conventional intraoral
periapical films in different projections., an intraoral
occlusal film was exposed in an axial-vertex projection,
with the x-ray beam parallel to the long axis of the
incisors. An orthopantogram and lateral head film also
were obtained. In those cases in which the canines could
not be projected free from the lateral incisors and the
overlapping made it impossible to rule out resorption,
the lateral incisors were polytomographed (for a detailed
description, see Ericson and Kurol.). A. complete ra-
diographic examination is illustrated in Fig. 1.
The panoramic image was obtained with a Siemens
Orthopantomograph (OP-3) modified with a collimator
system and rotating anode. The patient was carefully
*Siemens Corporation, Icrlin, N I.
506 Ericson and Kurol Am. J. Orthod. Dent&c. Onhop.
December 1988

Table I. Analyzed factors and their statistical correlation to resorption of maxillary lateral incisors caused
by ectopic eruption of the canine in a group of 40 resorbed incisors (I) and a group of 118 nonresorption
cases (II) after ectopic eruption
I-II Level of Power
Variables test values significance (phi or Cramers V)

Sex x2 = 3.77 (DF 1) p 5 0.05 0.16

Degree of canine maturation x2 = 14.31 (DF 1) p 5 0.002 0.31
Canine position relative to the midline of the dental arch (trans- x2 = 1.80 (DF 3) NS -
verse plane)
Canine position relative to the lateral incisor root (transverse plane) x2 = 1.83 (DF 4) NS -
Medial position of the canine cusp:
-Panoramic image (frontal plane) x2 = 23.07 (DF 4) p 5 0.0001 0.39
-Axial projection (transverse plane) x2 = 24.67 (DF 4) p I 0.0002 0.40
Angle of canine mesial eruption to midline, (Y (panoramic image) t = 4.62 (DF 154) p~O.ooo 0.12
Angle of canine mesial eruption to long axis of lateral, p (pan- t = 2.93 (DF 154) p 5 0.004 0.05
oramic image)
Angle of canine eruption in sagittal plane, 6 (lateral head film) t = 0.13 (DF 156) NS -
Angle of canine mesial inclination to midline, y (axial projection) t = 3.89 (DF 156) p 5 0.000 0.09
Degree of vertical eruption:
-Panoramic image (d,) t = 2.10 (DF 154) p 5 0.04 0.02
-Lateral head film (d,) t = 1.23 (DF 156) NS
Distance from canine cusp to APg line (lateral head film) t = 2.03 (DF 156) p 5 0.04 0.02
Proclined lateral incisor x2 = 0.04 (DF 1) NS -
Distal tipping of lateral incisor x2 = 0.14 (DF I) NS -
Enlarged follicular width x* = 0.00 NS
Apical canine root deflection x2 = 1.90 (DF 1) NS -
Degree of resorption of primary canine x2 = 6.67 (DF 3) NS

KEY: x2 = Chi-square analysis; t = Students t test; DF = degrees of freedom; p = probability; NS = nonsignificant.

Table II. Distribution of the most medial position of the cusp of the ectopically erupting maxillary canine
(sectors l-5) as projected in the orthopantogram (%)
Canine position in sector (%)
Level of
Group 5 4 3 2 I Total (%) significance

Resorption (n = 40) 3 31 42 I9 5 100

p cc 0.001
Control (n = 118) 33 39 20 7 0.8 100

oriented to the x-ray machine and clinical measurements
of the mesiodistal width of the maxillary incisors were
made and compared with the orthopantograms to ensure
an optimal position of the x-rayed object within the
image-processing layer.
The lateral head films were obtained with a focus
distance of 155 cm and with the beam of the x ray
directed through the external auditory meatus.
Analyzed factors
Twenty-four variables were analyzed. The data
were transferred to magnetic tape and analyzed by com-
puter. The SPSS computer program was used. This
presentation focuses on the following factors:
Canine
-Degree of development (mineralization)
-Path of eruption in all three planes
-Position of the canine relative to the lateral incisor in all
three planes
The development (degree of maturation) of the maxillary
canine has been presented in two degrees:
1. The root is longer than the canine crown.
2. The root is shorter than the canine crown.
The positions, measured distances, and degrees can be
seen from Figs. 2 through 6.
Lateral incisor
The position of the lateral incisor within the dental arch
was clinically assessedand registered as normal or distally
tipped, proclined or not proclined.
Dental age was determined according to a method
developed by Gustafson and Koch.13 The tested vari-
ables are presented in Table I.
Space loss was measured with sliding calipers and
Volume 94 Resorption of mad/q incisors 507
Number 6

Fig. 3. Schematic illustration of the canine position in an axial-

Fig. 2. Schematic illustration of the projection of the canine in vertex intraoral radiograph and sectors (7 through 5) of the most
the panoramic image and sectors (7 through 5) of the most medial position of the canine cusp.
medial position of the crown.

amounted to 1 to 3 mm in three cases in the resorption

group.

Statistical methods
Conventional methods have been used for statistical
analysis.* Distributions have been studied by means of
the chi-square test with the Yates correction; differences
in means between two groups have been analyzed by
means of Students t test with n-2 degrees of freedom.
For those variables in which statistical significance
was found, the association was further analyzed, and
the strength of the statistical associations from obtained
differences was estimated and expressed with the co-
efficient phi and Cramers V for the chi-square tests
and with the coefficient omega for Students t test.14
Any influence of sample size on statistical significance Fig. 4. Schematic illustration of the inclination of the maxillary
was hereby eliminated. The coefficients assumed canine to the midline (a) and long axis of the lateral incisor (p)
a value between 0 and 1, depending on the strength in the panoramic image.
of the statistical association (Table I), where 0 means
complete independence and 1.00 a complete as-
sociation . was 3 : 1 in the resorption group and 6: 5 in the control
The reliability of the radiographic methods was es- group. The factor related to sex accounts for about 16%
timated according to Guilfords definitionI by studying (phi 0.16) of the variance of the score. Compared with
the variance between two determinations. No error ex- some of the other significant variables, sex was of com-
ists when the reliability coefficient is 1.OO. The coef- paratively little importance (Table I).
ficient varied between 0.92 and 0.94.
Canine tooth development
RESULTS The canine tooth development (measuring the length
The main results are presented in Table I, together of the root) was more advanced in the resorption group
with an estimate of the strength of the statistical as- than in the control group (Table I). In cases with re-
sociations of variables between the two groups. sorption, more than half of the root had developed in
nine of 10 cases as compared with a 6:5 ratio for con-
trols of the same age.
Resorption of maxillary lateral incisors was found Children in the resorption group had a dental age
to be more common in girls than in boys. The sex ratio close to the mean* (mean k 1 year) in 97% of the
50% Ericson and Km-01 Am. J. Orthod. Dentofac. Orthop.
December 1988

0A
Lye
A
80.

80.

40.
NL
20-

Fig. 5. A, Schematic illustration of the maxillary canine incli-

nation lo the midline (y) in an intraoral axis-vertex projection.
B, Diagram showing median values (Md) of the eruption angles
(CXand p) in the resorption group (R) and control group (C), the
range for 50% of the observations, and the total range.

cases. For children in the control group, the corre-

sponding figure was 90%.
Position
Position of the canine crown relative to the dental
arch (transverse plane). The position of the cusp of the
maxillary canine crown in relation to the midline of the
dental arch or relative to the lateral incisor (both in
buccal and lingual positions) did not significantly differ
between the two groups (Table I).
Medial position of the canine cusp (transverse and
frontal planes). A detailed analysis showed that the
cusp of the maxillary canine was positioned more me-
sially in the resorption group than in the control group
(Tables I and II). This difference was statistically sig-
nificant. An estimate of this variable showed that it
accounts for approximately 40% of the variance of ob-
tained scores. The projection of the canine position in
the orthopantogram and in the axial-vertex projection
showed similar patterns. The distribution of the position
of the cusp of the maxillary canine in the orthopanto-
gram can be seen from Fig. 2 and TablebII.
Fig. 6. A, Degree of vertical eruption of the maxillary canine (6)
registered as a distance d, in the panoramic image. B, Degree
of vertical eruption of the maxillary canine registered as a dis-
tance d2 in the lateral head film. AU, Nasal line; OL, occlusal
line; Afg, line from the A point to the pogonion. Also shown is
the angle between NL and the long axis of the maxillary canine.
From Tables II and III, it can be seen that the num-
ber of resorbed lateral incisors increased as a result of
a more medial position of the canine cusp. The differ-
ence between the two groups in this respect is significant
and the strength of this relationship is high (Table I).
In the resorption group, canines in the most medial
sectors (1 through 3) in the orthopantogram comprised
65% of the material, whereas the corresponding figure
for the control material was 28% (Table II). The cor-
responding figures for the axial-vertex projection were
60% and 28%, respectively (Table III). It is worth not-
ing that when the cusp of the canine was positioned
mesially to the lateral incisor (in sectors 1 and 2), the
risk of complications increased three times, and every
Volume 94 Resorption of maxilluryviksors 509
Number 6

Table III. Distribution of the most medial position of the cusp of the ectopically erupting canine in an
axial-vertex projection (%)
Canine position in sectors (YG)
Level of
Group 5 4 3 2 I Total (o/o) srgnifcance

Resorption (n = 40) 0 41 33 18 8 100

F < 0.001
Control (n = 118) 31 40 20 7 1 100

Table IV. The vertical inclination () of the eruption path of the canine in the orthopantogram measured
to the midline (a) and to the long axis of the lateral incisor (@)-Mean, standard error, and
standard deviation

Group x SE SD x SE SD

Resorption (n = 40) 29.5 t 2.5 15.4 39.1 -c 2.5 15.5

Control (n = 118) 18.6 2 I.0 Il.5 31.1 2 1.3 14.2
Level of significance p < 0.001 p < 0.01

second lateral incisor was found to be resorbed with
canines in this medial position.
Inclination
Vertical inclination of the canine path of eruption.
The vertical inclination of the canine was analyzed both
from the orthopantogram and from the lateral head film
(Figs. 4 and 6).
Inclination of the canine in the frontal plane. In the
orthopantogram, the inclinations of the eruption path to
the midline (a) and to the long axis of the lateral incisor
(p) were measured. The mean values and standard de-
viations for these two angles are shown in Table IV.
When measured to the midline ((-u-29.5 and 18.6,
respectively) and also to the long axis of the laterals (p
39.1 and 31. l, respectively), the inclination of the
erupting canine was more horizontal (average 10) than
that of the control group. This difference between the
two groups was statistically significant and more pro-
nounced for the inclination to the midline (CL).The range
in individual variation was considerable, however, and
the strength of the association was thus found to be
fairly low-5% to 12% (Table I).
For the vertical inclination angles a and p, the me-
dians and the 50% quartiles were calculated (diagram
shown in Fig. 5, B). The inclination angle (Y ranged
from 8 to 80 in the resorption group and from 0 to
59 in the control group, the median values being 28
and 17, respectively. It was found that 25% to 75%
of the observations could be found between 18 and
40 and between 10 and 25, respectively. This indi-
cates that the risk of resorption increases by 50% when
the eruption inclination exceeds 25 as compared with
the controls. The corresponding value for the vertical
eruption inclination to the lateral incisor (p) is 28. This
is valid for the positions (buccolingually) as expressed
in the orthopantograms.
Inclination of the canine in the sagittal plane. The
sagittal inclination of the path of eruption (6) was mea-
sured in lateral head films (Fig. 6); no statistically sig-
nificant differences were found between the two groups.
Inclination of the canine in the horizontal plane.
The degree of mesial orientation of the canine was
analyzed by measuring the angle (y) between the pro-
jections of the long axis of the canine and the midline
of the maxilla in the axial-vertex occlusal film (Fig.
5). The values are presented in Table V. In the resorption
group, the mesial inclination of the canine to the midline
in the horizontal plane was more pronounced (34.5)
than in the control group (16.4). This difference be-
tween the groups was statistically significant.
Canine eruption in the vertical dimension
The degree of vertical canine eruption was analyzed
by measuring the distance (d,) from the canine cusp to
the occlusal plane in the orthopantogram (Fig. 6). The
results can be seen in Table VI; they show a statistically
significant but small difference between the two groups.
However, the strength of the statistically significant as-
sociation is low. When calculating means and 50%
quartiles, no definite difference could be found between
the two groups.
510 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Table V. The mesial inclination of the canine to the midline (6) of the canine in an axial-vertex
projection-Mean, standard error, and standard deviation
6
Level of
Group x SE SD significance

Resorption (n = 40) 34.5 k 4.5 29

p < 0.001
Control (n = 118) 16.4 2.2 24

Table Vi. The distance from the canine cusp to the occlusal line in orthopantograms (d,) and lateral head
films (d,)-Mean, standard error, and standard deviation
d, (orthopantogram) dz (lateral headjlm)

Group x SE SD x SE SD

Resorption (n = 40) 14.1 t 0.6 4.5 10.7 * 0.5 3.6

Control (n = 118) 15.6 2 0.3 3.8 11.4 -t 0.3 3.4
Level of significance p < 0.05 NS

Tabts WI. Distribution of the degree of root resorption of the primary canine (1 and 2) or absence (3)
(0 denotes no resorption)
.53163 of resorption (%)
Level of
Group 0 1 2 3 Total (%) significance

Resorption (n = 40) 35 17.5 17.5 30 100

NS
Control (n = 118) 34 34 18 14 100

Canine position in the sagittai plane
The canine position in the sagittal plane was mea-
sured as the distance between the cusp and the line APg
(A point to pogonion) in lateral head films (Fig. 6). A
small but not statistically significant difference was
found between the two groups.
The width of the dental follicle
The influence of the dental follicular width (mea-
sured in intraoral periapical radiographs with calipers)
was analyzed by comparing two groups, one with a
maximum width of 3 mm or more and another with a
maximum width less than 3 mm. The distributions were
then tested between the resorption group and the control
group and no difference was found. In intraoral radio-
graphs, the dental follicles exceeded 3 mm in 23% and
24% of the subjects in the resorption and control groups,
respectively.
No such association was found (Fig. 7, Table VII). In
one third of the resorption cases, normal resorption of
the primary canine root was found.
The position of the lateral incisor relative to the
dental arch
When compared to adjacent incisors clinically, in
the axial-vertex projection, and in the orthopantogram,
the position of the lateral incisor relative to the dental
arch was registered as (1) proclined or normal and (2)
distal tipping or normal for the two groups (Table I).
No association was found between the position of the
lateral incisor and the lateral incisor root resorption. In
the resorption group, 16% of the lateral incisors were
proclined and 27% were distally tilted; the correspond-
ing figures for the control group were 18% and 23%,
respectively. Most proclinations were associated with
buccal positions of the canine.

Resorption of the primary canine root DISCUSSION

The association between lateral incisor resorption Root resorption of permanent incisors caused by an
and the degree of the so-called physiologic root re- erupting maxillary canine is an underestimated prob-
sorption or absence of the primary canine was tested. 1em.6 Immediate therapeutic measures often are needed
Volume 94
Numhcr 6
to avoid worsening of the situation and subsequent pro-
longed and expensive orthodontic treatment. Several
predisposing and singularly associated factors involved
in the resorption of incisors due to canine ectopic erup-
tion have been identified in this study and their impor-
tance evaluated. The possibility of any covariation of
the analyzed factors has not been assessed and needs
further study.
The subjects in this study were younger than those
in other reports because of the screening procedure
used. The age ranges of the resorption and control
groups (10 to 15 years) cover the entire normal eruption
period of the canine and differ on average only 0.7 of
a year. Furthermore the number of subjects is large for
this uncommon complication. This material therefore
may be considered representative for identification of
factors associated with resorption of lateral incisors
caused by ectopic eruption of maxillary canines.
The conventional clinical and radiographic methods
used are representative of an everyday clinical situation
and have been used to present an analysis that facilitates
the everyday use of the results. Of the radiographic
methods used, the intraoral periapical and axial-vertex
projections in occlusal films and the panoramic image
were the most efficient in identifying differences in
position between the resorption and control groups.
Used together, these three methods describe the dis-
placed canine in three dimensions and can be expected
to have a sufficient degree of accuracy in describing
the relationship of the canine to the adjacent incisor
and to other anatomic structures. The detailed analysis
of the results also showed good agreement among these
methods (Tables III through V). The lateral head tilm
was less efficient in this respect because of the over-
lapping of the two sides, which made identification of
the specific canine difficult. The curve of the dental
arch in the canine region was also a factor.
The posterior-anterior (PA) skull radiograph was not
used in this study since it has been shown by Coup-
land, that this radiograph is comparable to the ortho-
pantogram in the presentation of the position of the
canine. The orthopantogram was chosen because it bet-
ter describes the dental situation in the anterior region
without disturbing the overlap and can be obtained at
many orthodontic departments, whereas the PA skull
radiograph is not as available. Most panographic ma-
chines give approximately comparable images in the
central part of the cut, provided that the orientation of
the patient is correct.
In all radiographic techniques, there is some degree
of distortion. Comparing the position of the canine in
two series of observations in this study, the distortion
factor did not influence the main results in a decisive
way because the same methods were used and the two
groups showed similar locations of the canine relative
Rt~sorption of maxillary incisors 511
DEGREE OF RESORPTION
TOOTH 53/63
--____--__
__________
0
---____
_ _-_-_-__-_
1
~ -- - ____-_--_
__-____ 2
--_---_ - --------3 (missing)
Fig. 7. Schematic illustration of the degree of root resorption of
the primary canines.
to the dental arch. Guilfords coefficient of reliabilityI
was high for all measurements of both inclination and
distance in the panoramic and vertex images, indicating
that the errors of the methods were low as compared
with the total variance of the measured variables.
The results show that ectopic eruption per se does
not increase the risk of resorption unless accompanied
by other factors. The factors that most increased the
risk were a more medially positioned canine crown, a
more advanced degree of canine development, and an
increased mesial inclination of the path of eruption. Of
the angles of eruption, (Yand y had greater power than
p, which would indicate that tipping of the lateral in-
cisors to a certain extent moderates the risk of resorp-
tion. Townend has reported that canines causing re-
sorption appeared to be more vertical, which is contrary
to the findings of this study. Female sex also was as-
sociated with the occurrence of resorption as indicated
earlier by Howard and Sasakura and associates. The
estimates of the strength of the statistical associations
do not give much consideration to mutual relationship
and covariations. It may well be that a discriminant
analysis could better explain the strength of these as-
sociations.
Of the clinical factors that may influence resorption
during ectopic eruption of the canines, we gave partic-
ular attention to the lateral incisors proclination and
tipping, the width of the canines dental follicle, and
the degree of primary canine root resorption. No sig-
nificant associations could be demonstrated in this
study. This is in contrast to earlier observations and
opinions in which such factors have been stated to be
associated with resorption, -namely, tipping of lateral
incisors,2o an enlarged canine follicle in some resorption
cases, and delayed resorption and exfoliation of the
primary canine..
512 Ericson and Kurol Am. J. Orthod. Dentofac. Orthop.
December 1988

Among possible causative factors in ectopic erup- ods should be based on individual indications according
tion and impaction of maxillary canines, lack of space to our previously suggested clinical and radiographic
and crowding in the canine region have been proposed procedures. *.I0
to influence ectopic eruption.~3~5~20~22 It has been sug- It is customary in scientific articles to express as-
gested, however, that most such patients have sufficient sociations with some sort of statistical significance, usu-
space. 6~2~23-25 In this study of resorbed lateral incisors, ally in the form of certain previously chosen levels
lack of space was found in only three of the 40 cases of statistical significance-for example, *** = p <
and was apparently of minor importance. 0.001. However, the occurrence of such a significant
For diagnostic awareness, it is important to note result discloses nothing about the strength of the as-
that the relative prevalence of the most common site of sociation among the tested variables.4 For this reason
resorption was not greater in palatal positions (which we have performed an analysis of the statistical power
is a far more common ectopic position compared with of the associations to evaluate the most important single
buccal ones). However, it is interesting that resorption factors that are easily recognized by the clinician.
was far more common in the middle third of the root It is also our opinion that it is very important, es-
than in the cervical and apical thirds, which is contrary pecially when studying causative factors, to analyze the
to Kettle, who believed apical resorption to be more strength of the associations in addition to the signifi-
common. Thus this midroot location of resorption in cance. This study could in this respect point out three
the sagittal and vertical dimensions means that, because powerful factors-namely, more advanced canine de-
of overlapping, diagnosis from intraoral or even pan- velopment, a more medial position of the canine cusp,
oramic films is not always reliable. and mesial inclination of the canine to the midline ex-
The importance of polytomography in diagnosing ceeding 25 as measured on the orthopantogram.
resorption in these cases has been evaluated earlier by
Ericson and Kurol.6 Polytomography, which is gaining CONCLUSION
increasing use for localizing unerupted teeth,2.6.8.26 In general, the results show that the typical candi-
should be considered when resorptions cannot be ruled date for resorption of the lateral incisors during ectopic
out from routine intraoral films. Another possible tool eruption is a girl approximately 11 to 12 years of age,
is computed tomography.* with (1) a well-developed canine root, (2) the canine
An advanced canine root development was signif- cusp erupted medially to the long axis of the adjacent
icantly correlated to resorption on adjacent incisors as lateral incisor, and (3) the canine in a mesial angle of
was a more medial position of the canine crown. Both eruption to the midline exceeding 25. However, be-
of these factors may be assumed to be age-related. cause the pattern is not uniform and resorption also may
It may therefore be concluded that early diagnosis occur in apparently normal eruption situations, the risk
of ectopic eruption and potential resorptive situations of resorption in children with displaced canines must
should reduce the number of complications. Annual not be neglected.
clinical investigation, including palpation of the canine
REFERENCES
region and relating this to the patients somatic and 1. Thilander B, Jakobsson SO. Local factors in impaction of max-
dental maturity, may show cause for a radiographic illary canines. Acta Odontol Stand 1968;26:145-68.
investigation of the canine position starting at 10 years 2. Ericson S, Kurol J. Radiographic assessment of maxillary canine
of age at the latest,*. and may help to reduce the eruption in children with clinical signs of eruption disturbance.
Eur J Orthod 1986;8:133-40.
number of complications caused by eruption distur-
3. Hitchin AD. The impacted maxillary canine. Br Dent J
bances. This is especially important because it has been 1956;100:1-14.
stated that lateral incisor resorption is unpredictable* 4. Rayne J. The unerupted maxillary canine. Dent Pratt 1969;
and rapid.5.20.29.31 It is noteworthy that in the resorption 19:194-204.
group, one third of the primary canines showed normal 5. Howard RD. The displaced maxillary canine positional variations
associated with incisor resorption. Trans Br Sot Study Orthod
physiologic root resorption. Thus the discovery of such
1970-1;57:149-57.
normal primary root resorption is no guarantee that the 6. Ericson S, Kurol J. Radiographic examination of ectopically
canine is free from complications. erupting maxillary canines. AM J ORTHOD DENTOFAC ORTHOP
Resorption may occur as early as 10 years of age 1987;91:483-92.
but the prevalence of such unfortunate resorption and 7. van der Linden FPGM, Dutterloo HS. Development of the human
dentition. An atlas. Hagerstown, Maryland: Harper & Row,
the degree of resorption seem to be 10w.~ Therefore
1976.
general radiographic screening at this age is not rec- 8. Ericson S, Kurol J. Resorption of permanent incisors due to
ommended for both practical and ethical reasons. Our eruption of maxillary canines. A radiographic study. Angle Or-
opinion is that the use of radiographic diagnostic meth- thod 1987;57:332-46.
Volume 94 Resorption of maxillary incisors 513
Numhrr 6

9. Marks SC Jr, Cahill DR. Regional control by the dental follicle 21. Dewel BF. The upper cuspid. Its development and impaction.
of alterations in alveolar bone metabolism during tooth eruption. Angle Orthod 1949;19:79-90.
J Oral Path01 1987:16:164-9. 22. Bass TB. Observations on the misplaced upper canine tooth.
10. Ericson S, Kurol J. Longitudinal study and analysis of clinical Dent Pratt 1967;18:25-33.
supervision of maxillary canine eruption. Community Dent Oral 23. Trlnkmann J. Zur Indikation der operativen Freilegung und An-
Epidemiol 1986;14:172-6. schlingung retinierter oberer Schneide- und Eckzlhne. Dtsch
Il. Iikubo M. Korsell S, Omnell K-A. Description of a new Zahnaerztl Z 1967;22:695-8.
cephalostat and its performance. Dentomaxillofac Radio1 1975: 24. Richardson A, McKay C. Delayed eruption of maxillary canine
4~25-9. teeth. Part 1. Aetiology and diagnosis. Proc Br Paedod Sot
12. Nie N, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. Statis- 1982;12:15-25.
tical package for the social sciences. 2nd ed. New York: 25. Jacoby H. The etiology of maxillary canine impactions. t\M J
McGraw-Hill, 1975. ORTHOD 198384: 125-32.
13. Gustafson G, Koch G. Age estimation up to 16 years of age 26. Cugat Femandez de la CA, Asensi CC, Gascon MF. Aplicacion
based on dental development. Odontol Revy 1974;25:297-306. de la tomogralia multidirectional al estudio de piezas dentarias
14. Hays WL. Statistics for the social sciences. 2nd ed. New York: incluidas. Acta Estomatokjgica Valenciana 1986; I :3- 10.
Holt, Rinehart & Winston, 1973:414-24. 27. Ericson S, Kurol J. CT diagnosis of ectopicaily erupting max-
15. Guilford JP. Introduction to analysis of variance. In: Funda- illary canines. A case report. Eur J Orthod 1988: 10: 115-2 1.
mental statistics in psychology and education. 4th ed. New York: 28. Hotz R. Orthodontics in daily practice. Bern, Switzerland: Hans
McGraw-Hill, 1965:268-303. Huber, 1974:340-53.
16. Coupland MA. Localisation of misplaced maxillary canines. Or- 29. Moss JP. The unerupted canine. Dent Pratt 1972:22:241-8.
thopantomograph and P.A. skull views compared. Br J Orthod 30. Kisling E, Ravn E. Two cases of marked pressure resorption in
1984:11:27-32. maxillary incisors. Tandlaegebladet 1977;81: 153-5.
17. McDavid WD. Tronje G, Welander U, Morris CR, Nummikoski 3 1. Brown ID, Matthews RW. Apical resorption of a maxillary lateral
P. Imaging characteristics of seven panoramic X-ray units. J Int incisor from a misplaced canine in 17-year old. A case report.
Assoc Dent Maxillofac Radio1 1985[suppl 81. Br J Orthod 1981;8:3-5.
18. Townend PI. Resorption of the roots of upper incisor teeth due
Reprint requests to:
to misplaced canine teeth. Trans Br Sot Study Orthod 1967:
Dr. Jiiri Kurol
74-7.
Department of Orthodontics
19. Sasakura H. Yoshida T, Murayama S, Hanada K, Nakajima T.
The Institute for Postgraduate Dental Education
Root resorption of upper pennanent incisor caused by impacted
Jimvagsgatan 9
canine. An analysis of 23 cases. Int J Oral Surg 1984;13:299-
S-552 55 Jijnkoping
306.
Sweden
20. Kettle MA. Treatment of the unerupted maxillary canine. Trans
Br Sot Study Orthod 1957:74-84.