Vol. 113 No.

2 February 2012

The impacted maxillary canine: a proposed classification for

surgical exposure
Andrew R. Chapokas, DMD, MDS,a Khalid Almas, BDS, MSc, FDSRCS,b and
Gian-Pietro Schincaglia, DDS, PhD,c Farmington, CT
UNIVERSITY OF CONNECTICUT

Objective. One of the treatment options for the impacted maxillary canine is surgical exposure followed by orthodontic
forced eruption. Several surgical techniques have been introduced in the literature for the exposure of the impacted canine.
The aim of this study was to review the current literature and to introduce a classification for maxillary canine impactions
that includes guidelines for selecting the proper surgical approach.
Methods. Epidemiology of canine impaction, diagnosis, and surgical options for the exposure of an impacted maxillary
canine are discussed based on the current literature.
Results. Careful clinical examination and proper diagnostic imaging should be used to define the anatomical position of the
impacted canine. The surgical approach for exposure of impacted maxillary canines should consider the anatomical position
of the tooth in relation to the alveolar ridge and the amount of keratinized mucosa/gingiva.
Conclusions. The proposed clinical classification provides a structured approach to treatment based on impacted tooth
location and anatomical factors. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:222-228)

Impaction is defined as the failure of tooth eruption at
its appropriate site in the dental arch, within its normal
period of growth.1 The maxillary permanent canine is
the most commonly impacted tooth after the third mo-
lar. Following these, in decreasing frequency, are man-
dibular canines, premolars, and incisors.2,3
Aside from their importance in an ideal mutually
protected occlusal scheme, the maxillary canine also
plays a key role in esthetics and continuity of the dental
arch.4 Several complications may result from impaction
of teeth, including esthetic and phonetic compromises,
loss in arch length, and referred pain.5,6 Options for
management of impacted canines include surgical ex-
posure followed by orthodontic forced eruption, re-
placement using fixed prosthodontics with and without
dental implants, and removable prosthodontics.
The purpose of this article was to review the litera-
ture on the impacted maxillary permanent canine and
a
Former Resident of Graduate Programs in Prosthodontics and Peri-
odontology, Department of Reconstructive Sciences, University of
Connecticut, School of Dental Medicine. Currently in private prac-
tice, San Diego, CA.
b
Director International Fellowship in Advanced Periodontics & As-
sociate Professor, Division of Periodontology, University of Con-
necticut, School of Dental Medicine.
c
Graduate Program Director and Associate Professor, Division of
Periodontology, University of Connecticut, School of Dental Medi-
cine.
Received for publication Dec 7, 2010; returned for revision Feb 9,
2011; accepted for publication Feb 14, 2011.
© 2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
doi:10.1016/j.tripleo.2011.02.025
introduce a classification that will guide the clinician
selecting the treatment sequence and the surgical tech-
nique for exposure.
ETIOLOGY AND PREVALENCE OF MAXILLARY
CANINE IMPACTION
An extensive list of etiologies causing maxillary per-
manent canine impaction has been reported.6-9 Some
common local causes include one or a combination of
the following: (1) overlying cysts or tumors, (2) super-
numerary teeth, (3) loss of arch space, (4) over-retained
primary teeth, (5) ankylosis, (6) root dilacerations, (7)
trauma, (8) reconstructive surgery for cleft lip/palate
repair, (9) thickened overlying bone or soft tissue, (10)
missing adjacent lateral incisor,10 or (11) idiopathic.6
Generalized tooth impaction has been associated with
certain host systemic disorders, including (1) endocrine
disorders, (2) febrile illness, (3) irradiation, (4) Gardner
syndrome,8 (5) cleidocranial dysostosis,9 and (6) Yu-
nis-Varon syndrome.11
Prevalence of maxillary canine impaction ranges
from 1.0% to 2.5%,2,3,12-16 where 8.0% to 10.0%6,17 of
these cases are bilateral (Table I). Impaction of remain-
ing teeth in the permanent dentition is quite rare and its
documented prevalence ranges only from 0.04% to
0.35%.13 Considering gender and location, impaction
of the maxillary permanent canine is twice as common
in females.6 Palatal impaction of the maxillary perma-
nent canine has been reported to occur approximately 3
times more frequently than facial impaction.18 In a
more recent investigation using cone-beam computed
tomography (CBCT), 45.2% of maxillary canines were

222
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Volume 113, Number 2
Table I. Prevalence and male/female ratio for unilateral maxillary canine impaction
Investigators Location
13
Dachi, 1961 Dental school, Portland, OR
Bass, 196715 Royal Victoria Hospital, Bournemouth, England
Rayne, 196916 Department of Oral Surgery, Oxford, England
Thilander, 19683 School system, Umeå, Sweden
Grover, 19852 Walter Reed Medical Center, Washington, DC
Ericson, 198612 Departments of Oral and Maxillofacial
Radiology and Orthodontics, Jönköping,
Sweden
—, Information was not reported by the authors.
impacted labially, 40.5% were impacted palatally, and
14.3% were impacted in the midalveolus.19
DIAGNOSIS
In subjects with a canine retained in the maxillary arch,
after the normal period of growth, the diagnosis of
impacted maxillary canine is immediate.
Conversely, in a patient with developing dentition,
maxillary canine impaction is more difficult to diag-
nose. The presence of certain clinical conditions, such
as lack of available arch space, have been considered as
risk factors significantly correlated to lack of spontane-
ous eruption.1,12,20,21 However, this may be dependent
on the location of the impacted tooth. According to
Jacoby,22 approximately 85% of palatally impacted
maxillary canines have sufficient arch space for erup-
tion, whereas only 17% of impacted maxillary canines
are located in a facial position. Increased angulation of
the canine long axis with respect to the interincisor
vertical midline has also been associated with risk of
impaction.12
Information on the prevalence of spontaneous eruption
of the impacted maxillary canine in growing subjects is
lacking. Data are available only on the prevalence of
spontaneous eruption of impacted maxillary incisors.21
Sixty-three patients with retained permanent maxillary
incisors were followed after removal of the associated
supernumerary tooth/teeth. Only 50% of these teeth
erupted without surgical and orthodontic assistance. No
relationship could be determined between spontaneous
eruption and several potential risk factors, which included
patient age, number of supernumeraries, extent of root
formation, and marked apical displacement of the im-
pacted tooth. In a similar study, 53 children had surgical
removal of supernumerary teeth associated with impac-
tion of maxillary incisors.20 Approximately half of the
patients required a second operation to facilitate orthodon-
tic forced eruption of the impacted tooth. Because only
50% of impacted teeth seemed to erupt without orthodon-
tic assistance, these studies support immediate application
of orthodontic forces after surgical exposure. This elimi-
ORIGINAL ARTICLE
Chapokas et al. 223
n Age, y Prevalence Male: Female
1685 13-20⫹ 0.92% 0.5:1
9102 10-20 1.65% 0.5:1
12,000 Unclear 1.5% —
384 Followed from mean ⫽ 1.8% 4:3
11.5 – mean ⫽ 17.8
5000 17-26 1.42%*** —
505 8-12 1.7% —
nates the need for a second surgical procedure if sponta-
neous eruption fails to occur.
PATIENT ASSESSMENT
Clinical evaluation of the patient with an impacted
maxillary canine is initiated by careful inspection of the
labial and palatal tissues, and measurement of the width
of keratinized gingiva present in the canine area. Dur-
ing the visual examination, the clinician will evaluate
arch space available and maxillary lateral incisor incli-
nation. Afterward, palpation is performed labially and
palatally in search for the canine bud. This provides
information regarding potential location of the im-
pacted canine and periodontal anatomy.23,24 If the pri-
mary canine is present, mobility is assessed. The pres-
ence of significant mobility may relate to eruptive
movement of the permanent canine. Also, periodontal
parameters of adjacent teeth should be recorded, in-
cluding the amount of keratinized gingiva, presence of
tooth mobility, and attachment loss.
RADIOGRAPHIC ASSESSMENT
Radiographic methods used for localization of im-
pacted maxillary canines include orthopantomogram,
lateral cephalometry, parallax method, occlusal radiog-
raphy, CT, and CBCT with or without use of stereo-
lithographic models.23,25 Lateral cephalometry has
overlap as its major disadvantage for evaluation of
impacted maxillary canines. CBCT scans are useful for
determining presence of lateral incisor root resorption
and precise location of the impacted tooth.19,25 How-
ever, CT and CBCT scans are more costly and have
higher radiation exposure compared with conventional
radiography26-28; therefore, they are often reserved for
complex cases that have other imaging requirements or
when localization of impacted canines cannot be deter-
mined with traditional methods. As CBCT technology
advances, more affordable 3-dimensional imaging with
decreased radiation exposure will become available. In
the near future, increased CBCT usage compared with
conventional techniques is expected. At this time, or-
ORAL AND MAXILLOFACIAL SURGERY
224 Chapokas et al.
Fig. 1. A, The maxillary left impacted canine is approaching a position medial to the long axis of the adjacent lateral incisor,
which suggests palatal impaction in the orthopantomogram. B, However, the corresponding lateral incisor inclination shown in
the clinical photograph suggests labial or midcrestal impaction. Palatal impaction is expected for the maxillary right canine. Its
cusp tip is medial to the adjacent lateral incisor long axis, which presents with normal inclination seen clinically.
thopantomogram and parallax methods are the most
commonly selected and their use is described in more
detail herein.
The orthopantomogram yields a 2-dimensional view
of maxillary canine location. If the cusp tip of the
maxillary canine is medial to the long axis of the
adjacent lateral incisor, palatal location is most proba-
ble.29 If the cusp tip of the canine radiographically
overlaps the root of the adjacent lateral incisor and is
palpated labially, labial impaction is suspected. Severe
tipping of the adjacent maxillary lateral incisor often
accompanies labial canine impaction with this type of
medial radiographic orientation (Fig. 1, A and B).
Ericson and Kurol30 examined prognostic factors for
orthodontic treatment of maxillary impacted canines
based on the radiographic presentation on orthopantomo-
grams. According to the authors, as the canine cusp tip
approaches the midline and the inclination of its long axis
increases, an increased length of orthodontic treatment
time is expected. In addition, the risk of root resorption of
the adjacent lateral incisor is increased. In a separate
investigation, Crescini et al.31 evaluated the prognostic
role of pretreatment radiographic features on the post-
treatment periodontal status of intraosseous impacted
maxillary canines. Pretreatment variables included
tooth location and inclination on panoramic radio-
graphs. Posttreatment variables included pocket depth
and width of keratinized gingiva. Based on their results,
no pretreatment radiographic findings could be used as
prognostic indicators of the final periodontal status of
orthodontically repositioned maxillary canines.31
The parallax method, also known as Clark’s rule
(Same Lingual Opposite Buccal [SLOB]), is a radio-
graphic technique used to detect an object’s spatial
orientation. Briefly, 2 periapical radiographs are taken
at different x-ray tube projection angles. During com-
parison of these radiographs, a radiographic reference
point is selected on the image and the impacted tooth is
related to this reference.32,33 If the impacted tooth ap-
pears to shift in the same direction as the second x-ray
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February 2012
tube projection, it is located on the lingual aspect and
vice versa (Same-Lingual Opposite-Buccal). For exam-
ple, if the x-ray tube is shifted in a distal direction and
the canine moves distally with respect to a selected
radiographic reference, the location is determined as
palatal (Fig. 2, A and B). Shifting periapical radio-
graphs can help to provide more information about the
3-dimensional location of the impacted tooth.
CLINICAL CLASSIFICATION AND
TREATMENT PLANNING
Surgical approach will be based on the location of the
impacted tooth. A classification with 3 categories is
presented (Table II).
Class I
A Class I impacted maxillary canine is located pala-
tally. For this category of impacted canines, a surgical
approach with gingivectomy is recommended. Imme-
diately after exposure of the impacted tooth, a fixed
attachment appliance should be connected (Fig. 3).
Advantages of this approach include relative simplicity
of the procedure, potential for spontaneous eruption
following surgical exposure, and presence of a fixed
attachment should spontaneous eruption fail to occur.34
According to Schmidt and Kokich,35 most palatally
impacted canines will spontaneously erupt with simple
surgical excision of the overlying palatal tissue. Con-
versely, Ferguson and Parvizi34 showed that 5.1% of
impacted canines exposed with gingivectomy required
a second surgical procedure because of lack of sponta-
neous eruption. Immediate application of orthodontic
force after surgical exposure of a palatally impacted
canine should be considered with caution.1 A lateral
direction of erupting force may result in impaction of
the crown against the alveolar process. This can induce
nonphysiologic bone resorption that may increase the
duration of orthodontic treatment.1
OOOO ORIGINAL ARTICLE
Volume 113, Number 2 Chapokas et al. 225

Fig. 2. In this series of periapical radiographs, the x-ray tube was shifted distally for radiograph B in relation to radiograph A. Because
the canine appears to have moved in a mesial direction, its position is toward the labial according to the buccal object rule.

Table II. A proposed classification for the surgical

approach of maxillary impacted canines
Classification Location Surgical technique
I Palatal Gingivectomy
II Center of alveolar ridge Repositioned flap
or labial
III Labial to long axis of Apically positioned
adjacent lateral flap
incisor root

Potential for a longer postoperative recovery period

is the primary disadvantage reported for gingivec-
tomy.36 Postoperative discomfort questionnaires and
evaluation of analgesic usage have been studied to
assess differences in pain threshold between open and
closed eruption approach in the management of im-
pacted maxillary canines. Chaushu et al.36 found a
longer recovery period for the open compared with the
closed approach. However, no difference in general
daily activity was noted.
Class II
A Class II impacted maxillary canine is located in the
center of the alveolar crest or labial to the alveolar
crest, but not superimposed labially to the root of the
adjacent lateral incisor. In this case, a closed eruption
technique using a repositioned flap is recommended
(Fig. 4, A and B).18,37-41 For the closed eruption tech-
nique, a full-thickness mucoperiosteal flap is reflected,
allowing the clinician adequate access to the impacted
tooth. Following follicular debridement, a fixed attach-
ment is bonded to the impacted tooth, including a wire
or chain. The crestal incision should be made with 3
Fig. 3. Gingivectomy is the recommended surgical procedure
for a palatally impacted canine. A gold button and chain were
attached at the time of surgical exposure.
mm of keratinized gingiva labial to its location. After-
ward, the flap is returned to its original position and
sutured. The wire or chain will exit the flap and the
labial keratinized gingiva is totally preserved (Fig.
4, B). Ideally, depending on the direction of force,
this surgical technique can facilitate forced eruption
through an adequate zone of keratinized gingiva. In
cases where keratinized gingiva is lacking, the pa-
tient must be informed that a revision with additional
mucogingival surgery may be needed to optimize
esthetics.
The primary advantages of this technique include
less postoperative discomfort compared with gingivec-
tomy,36 as well as management of forced eruption
through a zone of keratinized gingiva. Disadvantages
include increased technique sensitivity, related to
ORAL AND MAXILLOFACIAL SURGERY OOOO
226 Chapokas et al. February 2012

Fig. 4. The maxillary left canine is positioned apically to the mucogingival junction and labially in the alveolar process. A, A
repositioned flap procedure was used. B, A chain was connected to the impacted tooth, exiting the flap through the crestal incision
after suturing.

proper soft tissue flap management, and increased

length of surgical treatment time, compared with the
open eruption approach.

Class III
A Class III impacted maxillary canine is located labial
to the root of the adjacent lateral incisor. The radio-
graphic evaluation of an orthopantomogram will reveal
a canine with its cusp tip over the root of the lateral
incisor, whereas the tooth bud will be palpable labially.
The lateral incisor is usually inclined palatally to ac-
commodate this orientation. For impacted canines in a
Class III position, an apically positioned flap (window
flap)17 is indicated.39 A partial thickness dissection, Fig. 5. The maxillary right canine is positioned labial to the
including 2 to 3 mm of the coronally attached gingiva long axis of the adjacent lateral incisor root. An apically
is carried out. The flap is then apically positioned using positioned flap (Window flap) was performed. (Courtesy of
2 parallel, vertical releasing incisions (Fig. 5). Using Dr. Murad Shaqman.)
this approach, the clinical crown of the impacted tooth
will be completely exposed. This allows the orthodon-
tist to visualize the impacted tooth. Eruption force tic force should start within a few days after surgical
vectors may then be selected minimizing potential dam- exposure.1
age to the lateral incisor.39 Also, following this tech-
nique, the width of the keratinized gingiva will increase DISCUSSION
during orthodontic forced eruption.42 Hence, increase A surgical classification of impacted maxillary canines
in the visibility of tooth orientation and preservation of has been presented relating the width of keratinized
keratinized gingiva are the primary advantages of this gingiva and tooth location to the recommended surgical
approach. Disadvantages of the window flap include its approach. Several potential complications may arise
higher level of technique sensitivity compared with following surgical exposure and orthodontic forced
gingivectomy and repositioned flap previously de- eruption of the impacted maxillary canine, including
scribed. Also, several authors have reported complica- root resorption, periodontal defects, poor esthetic out-
tions, including risk of soft tissue recession and inade- come, and immobility.
quate access to labial bone.1,18,37,38 For class II and Root resorption of incisors occurs quite commonly
class III canine impaction, the application of orthodon- when adjacent to impacted maxillary canines. The
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Volume 113, Number 2
prevalence is higher in females compared with males
ranging from 2:1 up to 10:1.43-47 Using CBCT, 27% to
38% of adjacent laterals and 9% to 23% of adjacent
centrals have been shown to exhibit root resorption
associated with an impacted canine.19,48
Although there has been anecdotal concern of peri-
odontal complications following forced eruption of im-
pacted maxillary canines, no significant increase in
periodontal pocket depth, recession, or width of kera-
tinized gingiva has been reported.10,17,31
In a retrospective study, the esthetic outcome on 16
patients treated with forced eruption of unilaterally
impacted canines was evaluated. A panel of orthodon-
tists and orthodontic residents were able to identify the
previously impacted tooth 78.9% of the time in post-
treatment photographs.35 Several reasons for identifica-
tion include torque/tooth inclination (28%), attached gin-
giva height compared with contralateral tooth (27%),
alignment (17%), crown length/wear (13%), and recession
(6%). To optimize esthetic outcome, orthodontic finishing
tooth movements and surgical soft tissue management
require careful attention to detail.
There are 3 possible causes of immobility: (1) bone
remaining around the crown of the impaction, (2) in-
appropriate orthodontic mechanics, and (3) ankylosis.1
Literature reporting the prognosis of treatment in rela-
tion to immobility is lacking.
If forced eruption of the impacted tooth is unsuccess-
ful, other prosthodontic options for tooth replacement
may be considered, including extraction followed by
implant placement, conventional fixed dental prosthe-
sis, and removable prosthesis. Dental implant place-
ment may have complications associated with extrac-
tion of the impacted tooth. Hence, reconstruction of the
alveolar process may be necessary to optimize the
esthetic outcome. Fixed prosthodontic options, such as
mesial cantilever and 3-unit fixed dental prosthesis
have acceptable long-term survival49-52; however, these
often require preparation of an otherwise healthy, non-
carious or restored tooth. Questionable long-term and
short-term survival has been reported for resin-bonded
fixed dental prostheses.53-55 More evidence is needed
regarding orthodontic prognosis of forced eruption
postsurgical exposure.
CONCLUSIONS
The impacted maxillary canine poses challenging in-
terdisciplinary diagnoses and treatment. The proposed
classification provides guidelines for selecting the sur-
gical approach based on impacted tooth location and
anatomical factors.
Special thanks to the University of Connecticut Hea-
lth Center, Department of Orthodontics, for their refe-
ORIGINAL ARTICLE
Chapokas et al. 227
rrals and support. Thanks to Dr. Murad Shaqman for pro-
viding the clinical image in Fig. 5.
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Reprint requests:
Gian-Pietro Schincaglia, DDS, PhD
Division of Periodontology
University of Connecticut
School of Dental Medicine
263 Farmington Ave
Farmington, CT 06030-1710
Schincaglia@uchc.edu