The European Journal of Orthodontics Advance Access published September 22, 2014

European Journal of Orthodontics, 2014, 1–10

doi:10.1093/ejo/cju040

Randomized controlled trial

Extraction of the deciduous canine as an

interceptive treatment in children with palatal
displaced canines—part I: shall we extract the
deciduous canine or not?
Julia Naoumova, Jüri Kurol and Heidrun Kjellberg
Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden

Correspondence to: Julia Naoumova, Department of Orthodontics, Institute of Odontology at the Sahlgrenska Academy,
University of Gothenburg, PO Box 450, SE-405 30 Göteborg, Sweden. E-mail: julia.naoumova@vgregion.se

Summary
Objectives:  To analyse whether extraction of the deciduous canines facilitates eruption of the palatal

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displaced canines (PDCs), and to analyse root resorption in adjacent teeth caused by the PDCs.
Materials and methods:  Eligibility criteria for participants were as follows: children at age 10-13 years
with either maxillary unilateral or bilateral PDC, persisting deciduous canine and no previous experience
of orthodontic treatment. Sixty-seven patients (40 girls and 27 boys; age: mean ± standard deviation:
11.4 ± 1.0) with unilateral (45) or bilateral (22) PDCs were consecutively recruited and randomly allocated
using permuted block randomization method to extraction or non-extraction. No patients dropped out
after the randomization or during the study. Patients underwent a clinical examination and cone beam
computed tomography at baseline (T0), after 6 (T1) and 12 months (T2). The total observation time
was 24 months. Outcome measures were eruption, positional changes, length of time until eruption,
and root resorption of adjacent teeth. The baseline images were measured blinded while the 6- and
12-month control images were not, since it was not possible to blind the extracted canine.
Results:  Significantly more spontaneous eruptions of the PDCs were seen in the extraction group
(EG) than in the control group (CG), with rates of 69 and 39 per cent, respectively, with a mean
eruption time of 15.6 ± 5.6 months in the EG and 18.8 ± 5.8 months in the CG. Significant differences
in changes between the groups, in favour of the EG, were found for all variables except for the
sagittal angle. In the EG, the changes in the distances of the canine cusp-tip were larger during
the first 6 months, while the change of apex was larger between 6 and 12 months. There were no
significant differences in resorption of adjacent teeth between the groups.
Limitations:  Imputation values were used for the PDCs who had erupted atT2, since no x-rays were taken
for ethical reasons, which might have given uncertainty in the positional changes between T1 and T2.
Conclusions:  Extraction of the deciduous canine is an effective treatment in patients with PDCs.
Significantly more positional changes and shorter mean eruption time were seen in the EG.
Resorptions of lateral incisors were seen in both groups, but none exceeded grade 2 (resorption
up to half of the dentine thickness to the pulp).
Registration:  This trial was registered in ”FoU i Sverige” (http://www.fou.nu/is/sverige), registration
number: 40921.
Protocol:  The protocol was not published before trial commencement.
Funding:  The Local Research and Development Board for Gothenburg and Södra Bohuslän and
from the Health & Medical Care Committee of the Regional Executive Board, Västra Götaland Region.

© The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
1
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2 European Journal of Orthodontics, 2014
Introduction
Prevention of palatally displaced canines (PDCs) from becoming
impacted is of significant importance because an impaction length-
ens the orthodontic treatment, complicates orthodontic mechan-
ics (1, 2), increases the treatment costs (3), and increases the risk of
root resorption of adjacent teeth with a potential result of tooth loss
(4–6). Early interceptive treatment is therefore desirable. The preva-
lence of PDC varies between 0.9 and 2.8 per cent and depends on
the patient’s ethnic origin, gender, and the diagnostic methods used.
Canine impaction occurs twice as frequently in females than in males
and 85 per cent of the impacted canines are located palatally (7–9).
The aetiology of PDC is still unknown, but two theories are widely
mentioned in the literature, i.e. the guidance theory (10, 11) and the
genetic theory 12–15.
One of the most common methods used to diagnose PDC is
comprised of two periapical radiographs taken from different views,
known as Clark’s rule (16–18). Cone beam computed tomography
(CBCT) has recently been presented for imaging the craniofacial
field, and several studies have reported the advantage of CBCT over
conventional radiographs for localizing canines and identifying root
resorptions on adjacent teeth (19–21).
Interceptive extraction of the deciduous canine was recom-
mended in 1936 to facilitate the eruption of the impacted maxillary
canines and prevent the risk of resorption (22). This treatment was
later evaluated in a prospective uncontrolled study by Ericson and
Kurol (23), who concluded that extraction in patients with PDCs is
an effective intervention and the success rate depends on the mesio-
distal location of the crown and the patient’s age at the diagnosis.
The authors presented a treatment protocol that is widely used by
many dentists all over the world.
However, in two newly published systematic reviews assessing
whether interceptive treatment in the mixed dentition prevents impac-
tion of PDC, it was concluded that the scientific evidence still is too
weak to fully evaluate the effect that interceptive treatment might have
on PDC (24, 25). Several randomized controlled trial (RCT) studies have
been published after the two systematic reviews, comparing extraction
of the deciduous canine to other treatment methods such as expansion
(26), space maintainer (27), or double extraction, i.e. extraction of the
deciduous canine concomitant to extraction of the first deciduous molar
(28). All three treatment methods resulted in more successful canine
eruption than extraction of the deciduous canine alone. A  new pro-
spective study comparing extraction of the deciduous canines with no
extraction on patients with bilateral PDC was very recently published
and concluded that extraction is an effective measure (29). According
to the studies mentioned previously, the results show that extraction of
the deciduous canine is effective in patients with PDC, but no previous
study has assessed the three-dimensional (3D) ‘depth’ of the impaction
and the outcome using the CBCT technique.
Therefore, the aims of this study were to
1. Evaluate the effect of interceptive extraction of the deciduous
canine in children with PDC compared with a control group
(CG) using an RCT methodology with a CBCT technique.
2. Assess the radiographic changes in eruption between the extrac-
tion group (EG) and the CG in time, i.e. between 0 to 6 and 6 to
12 months after extraction.
3. Analyse root resorption on adjacent teeth caused by the PDCs.
It was hypothesized that there are no significant differences between
the EG and the CG regarding 1)  the success rate of spontaneous
eruption of the PDC, 2)  change in eruption pattern, or 3)  for the
number of root resorptions of adjacent teeth, after interceptive
extraction of the deciduous canine.
Materials and methods
Trial design
This randomized controlled clinical trial with an equal patient allo-
cation to the two groups:
• Extraction group (EG)
• Control group (CG)
which took place at the clinic of orthodontics, University Clinics of
Odontology, Gothenburg, Sweden.
Patients with unilateral PDC were randomized either to have
extraction of the deciduous canine or non-extraction and patients
with bilateral PDC were randomized to have either the right or the
left deciduous canine extracted (Figure 1).
Registration
This trial was registered in ”FoU i Sverige” (http://www.fou.nu/is/sverige),
registration number: 40921.
Ethical issue
The research ethics committee of the Sahlgrenska Academy,
Gothenburg, Sweden, approved the protocol of the study (Dnr 578-
08). Children and parents received verbal and written information,
and informed consent was provided by the child and their parent or
by an adult with parental responsibilities and rights in accordance
with the Declaration of Helsinki.
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Screening of PDC
The general practitioner identified participants for the trial, who were
consecutively recruited from 15 public dental clinics in Gothenburg,
Västra Götaland County Council, Sweden, between September 2008 and
January 2011. During their visit to the public dental clinic, the consulting
orthodontist then invited the potential patients to participate in the study.
Subjects, eligibility criteria and setting
Study setting and eligibility criteria
Patients interested in participating received an appointment letter in
which a website (http://www.odontologi.gu.se/horntand.html) was
enclosed that contained information about the study. Another web-
site (http://www.odontologi.gu.se/horntand_tdl) was established for
the general practitioners and for the orthodontists, where they could
access information about the study.
The inclusion criteria were as follows:
• Caucasians at age 10–13  years with either maxillary unilateral
or bilateral PDC
• Persisting deciduous canine
• No previous experience of orthodontic treatment
The canine was considered palatally displaced when clinical palpa-
tion of a labial canine bulge was absent and when the canine crown
was diagnosed on intraoral radiographs as palatally positioned,
using Clark’s rule (30).
Criteria for exclusion were as follows:
• Crowding in the maxilla exceeding 2 mm
• Ongoing orthodontic treatment
• Resorption of the adjacent teeth, grades 3 and 4 according to
Ericson and Kurol (31), either at the start or during the trial
caused by the displaced canine.
• Craniofacial syndromes
• Odontomas, cysts
• Cleft lip and/or palate
J. Naoumova et al. 3

Assessed for eligibility

N = 70

Declined to enter the

study N= 3. Age (mean
± SD: 11.5±0.7)

Randomized patients N = 67
40 girls (mean age ± SD:
11.3± 1.1), 27 boys (mean
age ± SD: 11.4± 0.9)

Unilateral PDC bilateral PDCs

Allocated to non-extraction Allocated to extraction of Allocated to extraction of Allocated to extraction of the

N = 22; 7 boys, 15 girls the deciduous canine the right deciduous canine left deciduous canine
Age (mean ± SD: 11.3±1.1) N = 23; 9 boys, 14 girls N = 22; 11 boys, 11 girls N = 22; 11 boys, 11 girls
Age (mean ± SD: 11.2±1.1) Age (mean ± SD: 11.6 ± 1.0) Age (mean ± SD: 11.6 ± 1.0

Baseline, T0 Non-extraction of the Extraction of the deciduous

Clinical examination, CBCT deciduous canine i.e. control canine i.e. extraction group
N = 67 group (CG) (EG)

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(40 girls, 27 boys) N = 44 PDCs N = 45 PDCs

6 month control, T1 Non-extraction of the Extraction of the deciduous

Clinical examination, CBTC deciduous canine i.e. control canine i.e. extraction group
N = 67 group (CG) (EG)
(40 girls, 27 boys) N = 44 PDCs N = 45 PDCs

12 month control, T2
Clinical examination, CBCT Analysed
N = 67 N = 52 N = 89 PDCs
(40 girls, 27 boys)

Individual treatment plan

N =71 PDCs

Impairment or no Improved position

change of the canine of the canine
position
Clinical
Surgical exposure examination. X-
and orthodontic ray if needed, total
treatment observation period
N = 41 PDCs 24 months
N = 30 PDCs

N: number of patients, PDCs: palatally displaced canines; SD: standard deviation; CBCT: cone beam computer tomography

Figure 1.  Flowchart describing the protocol and the patients included in the study. No patients dropped out after the randomization or during the study.

The Ericson and Kurol (31) classification of root resorption is to the pulp or more, the pulp lining being unbroken; and 4) severe
1) no resorption, intact root surfaces, and the cementum layer may resorption, the pulp is exposed by the resorption. Resorption
be lost; 2)  slight resorption, resorption up to half of the dentine grades 3 and 4 were excluded from the trial, while 1 and 2 were
thickness to the pulp; 3) moderate resorption, resorption midway included.
4 European Journal of Orthodontics, 2014
A total of 70 patients were invited to take part in the study. Three
patients, all girls with bilateral PDCs, declined to participate at the
first visit when information was given about the study, i.e. before they
were randomized. Two out of the three patients declined due to fear
of extraction and one patient thought it was too far to travel to the
clinic of orthodontics, University Clinics of Odontology, Gothenburg,
Sweden. No patients dropped out after the randomization or during
the study. Thus, in total 67 patients were randomly allocated to the
extraction or the CG. Of these, 45 patients had unilateral PDC and
22 patients had bilateral PDCs (Figure 1).
Randomization method
For randomization, the permuted block randomization method was
used and the allocations were concealed in sequentially numbered,
sealed opaque envelopes opened by a dental nurse after the written
consent was obtained.
Treatment protocol and process
All patients who decided to participate in the study, regardless of the
group to which they were randomized, underwent a radiographic
examination consisting of CBCT images at the Department of Oral
and Maxillofacial Radiology, Institute of Odontology, Sahlgrenska
Academy, Gothenburg, Sweden. The radiographic examination is
explained in detailed in a previously published study (32). Extraction
of the deciduous canines was carried out by one orthodontist (JN)
on the same day as the baseline radiographic examination (T0) in
order to get a precise timing of the start of the intervention.
After 6 months (T1), patients in the EG and the CG were clini-
cally examined by the same orthodontist who carried out the baseline
examinations. If the permanent canine was not clinically visible, the
Figure 2.  Radiographic measurements of the cone beam computed tomography images assessed in coronal, sagittal, and axial plane.
patient underwent a new radiographic examination (CBCT images)
the same day. This procedure was repeated at the 12 month control
(T2). Figure 1 describes the protocol and the patients included in the
study. All patients were given a diary to document the date of the
eruption in those cases the canine started to erupt before the next
check-up. In patients with clinically visible canines, i.e. that emerged
through the gingiva, no further CBCTs were taken.
An individual treatment plan was drawn up for patients with
unerupted PDCs after 12  months. The unerupted canines, in cases
that the canine had improved its position on the radiographic exami-
nation, were followed until they emerged through the gingiva with
continuing check-ups in the EG. In the CG, the deciduous canine was
extracted if mobility of the tooth was not present. When the canine
showed impairment or no change in its position at the 12 month con-
trol, a combined surgical exposure and orthodontic treatment was
performed, regardless of the group to which the patient belonged.
Blinding
One oral radiologist unaware of the group to which the patients
belonged carried out all the measurements on the CBCT images in
axial, sagittal, and frontal views. The baseline images were, there-
fore, measured blinded, while the 6 and 12 month control images
were not because it was not possible to blind the extracted canine.
The following outcome measures were assessed:
Primary outcome
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• Eruption of the permanent canine, i.e. successful outcome
(defined as canine emerged through the gingiva) during the total
observation time, i.e. 24 months.
J. Naoumova et al. 5

Secondary outcome
• Positional changes of the permanent canine over time (T1–T0
and T2–T1) measured from the radiographs: mesioangular angle,
sagittal angle, vertical position, canine cusp tip-dental arch plane,
canine root apex-dental arch plane, canine cusp tip-midline
(Figure  2) and changes between T1–T0 and T2–T1 within and
between the EG and the CG.
• Root resorption of adjacent teeth.
Positive values for the variables: canine cusp tip-dental arch plane
and canine root apex-dental arch plane indicate a palatal position of
the cusp-tip or apex and a negative value buccal position in relation
to the dental arch plane.
The methodology of the radiographic measurements has been
described in detail in a previously published study, in which the intra-
and inter-examiner error of the 3D measurement and the validity of the
measured angles were also evaluated (32). All randomized patients were
included in the groups to which they were randomly assigned regardless
of the treatment they actually received and regardless of a deviation
from the protocol as randomized. Thus, in the analysis, the intention-to-
treat (ITT) approach was applied.
Imputation of measurement values
Missing data can introduce bias and affect the results because most
statistical packages ‘automatically’ discard cases with missing values.
non-EG, gender, extraction site, and extraction versus non-extrac-
tion. To test whether the bilateral group would be considered inde-
pendent observations or dependent paired observations, the main
outcome, i.e. eruption or non-eruption, was tested with Fisher’s
exact test and McNemar’s test. As no multiple comparisons have
been tested, adjustment or correction with statistical analysis was
not needed.
Harms
No harms were detected during the study.
Results
The extracted deciduous canines showed no root resorption or less
than one-third of the root length resorbed, and none were mobile.
Participant flow
Fifteen out of the 67 patients (3 bilateral PDC and 12 unilateral PDC
[3 from the CG and 9 from the EG]) did not have a radiographic
examination at the 12  month control because the canines had
emerged through the gingiva and were under eruption, i.e. clinically
visible between T1 and T2. Imputation values were used in these cases
(Figure 1).
Baseline findings
There were no significant differences at T0, either for the mean age

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This can be avoided by applying imputation, a statistical process of
between the unilateral and bilateral groups (Table 1) or between the
replacing missing data with probability values based on other avail-
angular and linear measurements in the EG and the CG (Table 2).
able information. In this case, angular and linear measurements of
Dividing the subject into age groups of 10–11- and 12–13-year-old
fully erupted maxillary canines were imputed.
individuals showed that there were a larger number of patients in
As described previously, in patients in whom the permanent
the younger group. There were more females than males in total, but
canine had started to erupt and was clinically visible, no further radi-
no significant differences were seen in gender distribution between
ographic examinations were done. Instead, imputation values were
the unilateral and bilateral groups or the extraction and non-EGs. In
used (applicable only at T2, 12 months), which were calculated by
addition, no differences were seen between the left and right extrac-
measuring the mean angular and linear measurements of 10 unilat-
tion sites (Table 1).
eral patients (8 girls, age: mean ± standard deviation [SD]: 11.2 ± 0.9;
It was decided to analyse the whole material and not only the
2 boys, 11.7 and 10.6 years of age at baseline), whose contralateral
unilateral group as two independent observations because there was
non-PDC was fully or partial erupted.
no difference in the correlation between extraction and successful
outcome between independent observations and dependent paired
Sample size calculation observations in the bilateral group. Further, there were no significant
The sample size was based on the alpha significance level of 0.05 and differences in the patients’ characteristics when the bilateral and uni-
a beta of 0.10 to achieve a 90 per cent power to detect a difference of lateral PDC patients were put together in the EG and CG.
5 degrees (SD 6.38) of the angle measured in the frontal and sagittal
views, between the extraction and the CG. The calculation indicated
Table  1. Patient characteristics in the unilateral and bilateral
that in total 60 patients with unilateral PDC were needed, i.e. 30
groups at baseline. PDC, palatal displaced canines; SD, standard
patients in each group. Inclusion of bilateral PDC reduced the num-
deviation
ber of patients needed. To compensate for possible dropouts during
the study, in total 70 patients were identified, 67 were enrolled. Unilateral PDC Bilateral PDC Total

Patients (n) 45 22 67
Statistics Age (mean ± SD) 11.2 ± 0.9 11.6 ± 1.0 11.4 ± 1.0
The data were statistically analysed using SAS, version 9.3 for Age (y), n (%)
 10–11 30 (67) 13 (59) 43 (64)
Windows (SAS Institute Inc., Cary, North Carolina, USA). Arithmetic
 12–13 15 (33) 9 (41) 24 (36)
means and standard deviations were measured for numerical vari-
Female, n (%) 29 (64) 11 (50) 40 (60)
ables. Dependent and independent t-tests were used to compare Male, n (%) 16 (36) 11 (50) 27 (40)
the baseline variables and changes in time between and within the Extraction, n (%) 23 (51) 22 (49) 45 (51)
groups, respectively. The independent t-test was used to test whether   Right side, n (%) 7 (30) 13 (59) 20 (45)
there were any significant differences in the linear and angular vari-   Left side, n (%) 16 (70) 9 (41) 25 (55)
ables between successful versus non-successful outcome. Fisher’s Non-extraction, n (%) 22 (50) 22 (50) 44 (49)
exact test was used to calculate differences in categorical data, such
as the success in the eruption rate between the extraction versus the n indicates number of patients and % indicates percentage of patients.
6 European Journal of Orthodontics, 2014

Table  2.  Baseline variables (T0) for the unilateral and bilateral groups with mean, standard deviations (SD), and P-values. CG, control
group; EG, extraction group; PDC, palatally displaced canines; SD, standard deviation.

Unilateral PDC (patients, n = 45) Bilateral PDC (patients, n = 22)

EG (n = 23 CG (n = 22 EG (n = 22 CG (n = 22

PDC) PDC) PDC) PDC)

Mean ± SD Mean ± SD Mean ± SD Mean ± SD

P-value*
Variable at T0 11.2 ± 0.9 11.4 ± 1.1 P-value* 11.6 ± 1.0 11.6 ± 1.0 P-value* EG-CG

Mesioangular angle (°) 105.2 ± 5.4 107.7 ± 9.6 0.182 106.1 ± 7.1 108.0 ± 7.1 0.371 NS

Sagittal angle (°) 98.0 ± 8.1 101.1 ± 9.5 0.232 100.1 ± 8.6 99.6 ± 8.7 0.337 NS
Vertical position (mm) 15.9 ± 2.2 14.9 ± 2.4 0.178 14.6 ± 2.7 15.0 ± 2.3 0.597 NS
Canine cusp tip-dental arch plane (mm) 1.9 ± 1.2 2.5 ± 2.0 0.300 3.0 ± 1.0 3.2 ± 2.2 0.626 NS
Canine root apex-dental arch plane (mm) 2.2 ± 1.6 2.7 ± 1.7 0.224 2.8 ± 1.7 2.6 ± 1.8 0.654 NS
Canine cusp tip-midline (mm) 9.7 ± 2.2 9.2 ± 2.7 0.322 9.7 ± 2.6 9.3 ± 1.8 0.597 NS

NS, Not significant.

*P-value < 0.05 is considered statistically significant.

Primary outcome
Significantly more PDCs erupted on the extraction site compared
with the untreated control site, with a prevalence rate of 69 and 39
per cent, respectively, (P = 0.001). The mean eruption time in the EG
was 15.6 months (SD 5.6) and in the CG was 18.3 months (SD 5.8),
with no significant difference for the mean eruption time between
the younger (age 10–11 years) and the older patients (12–13 years)
The variables with significant changes between T0–T1 and T1–
T2 in the EG and the CG, respectively, are presented in Figure 3.
In the EG, significant larger changes between T0–T1 than T1–T2
were observed for the distance: canine cusp tip-dental arch plane
(P  =  0.0026) and canine cusp tip-midline (P  =  0.0276), while
the variable: canine root apex-dental arch plane (P  =  0.0085)
changed more between T1–T2 than between T0–T1 (Figure  3).

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(P  =  0.238). At T2, 14 PDCs in the EG and 27 PDCs in the CG When changes over time were compared between the groups,
had impairment or no changes of the canine position. These teeth the variables for the distances: canine cusp tip-dental arch plane
were surgically exposed and orthodontically treated. All remaining (P = 0.0013) and canine root apex-dental arch plane (P = 0.050)
PDCs that were followed up after T2 erupted in both groups, with deviated more between the EG and CG between T1–T2 than
the latest at the 24 month control (Table 3). Of 10 PDCs in the CG between T0–T1.
that were followed up, five deciduous canines without mobility were
extracted, while the mobile ones were left to spontaneously exfoliate. Root resorption of permanent adjacent teeth
Online supplementary figures 1 and 2 exemplify successful and None of the patients were excluded in this trial due to resorption
impaired changes in position of the PDCs with two patients. grades 3 and 4 of the adjacent teeth caused by the PDC either at
the start of or during the study. Thirteen patients (14 PDC) showed
Secondary outcome root resorption grade 2 on adjacent teeth at the start of the trial,
Positional changes of the canine over time observed by 16 patients (17 PDC) at the 6  month control and 20 patients (21
radiographic means PDC) at the 12 month control (Table 5). Although more teeth where
Between T0 and T1, five of six variables in the EG and three of six in resorbed in the CG than the EG, significant differences were not
the CG improved significantly. Between T1 and T2, five variables out found for either T1 (P = 0.4218) or T2 (P = 0.2123). The adjacent
of six in the EG and two in the CG improved significantly. Significant teeth that had root resorption caused by the PDC were all lateral
differences in changes between the groups, in favour of the EG, were incisors.
found for three of six variables between T0 and T1 and for all vari-
ables except for the sagittal angle between T1 and T2 (Table 4). Discussion
The effectiveness of extracting the deciduous canine as an intercep-
tive approach to achieve spontaneous eruption of PDC compared
Table  3.  Number of palatally displaced canines (PDCs) in the ex-
with non-extraction was investigated in this prospective, rand-
traction (EG) and the control group (CG) that had erupted, were
omized, clinical longitudinal trial. The findings in the study show
impaired or had not changed at the 6 month control (T1), 12 month
control (T2), or after T2 (>T2)
that extraction of the deciduous canine allows the PDCs to sponta-
neously correct in the majority of the cases. Significantly more radio-
EG (N = 45 PDCs) CG (N = 44 PDCs) graphical changes over time were noted in the EG. We can thereby
reject the first 2 null hypotheses. Although more adjacent teeth were
T1 T2 >T2 T1 T2 >T2
resorbed at T1 and T2 in the CG than the EG, significant differences
Erupted PDCs 0 11 20 0 7 10* were not found, i.e. we accept our final null hypothesis.
Impaired PDCs or — 14 — — 27 — As patients with both bilateral and unilateral PDC were
no changes included in the study, the tooth rather than the patient was used
as the unit of analysis. The observations in the bilateral group
*Note that five deciduous canines in the control group that were not mobile could preferably have been assessed as dependent paired observa-
(n = 5) were extracted at T2. tions but, as the same significant results were achieved when the
Table 4.  Positional changes over time of the permanent canine: T1–T0 (6 months–baseline) and T2–T1 (12 months–6 months) with mean, standard deviation (SD), mean differences, and 95%
confidence interval (CI), between the extraction (EG) and non-extraction (CG) site

T1–T0 (patients, n = 67) T2–T1 (patients, n = 67)

EG (n = 45 PDCs) CG (n = 44 PDCs) Differences EG-CG EG (n = 45 PDCs) CG (n = 44 PDCs) Differences EG-CG
J. Naoumova et al.

Variable Mean ± SD P-value* Mean ± SD P-value* Mean (95% CI) P-value* Mean ± SD P-value* Mean ± SD P-value* Mean (95% CI) P-value*

Mesioangular angle (°) −3.4 ± 5.8 0.000 −0.8 ± 5.8 0.369 −2.6 (−5.1, 0.030 −3.3 ± 6.4 0.000 −0.5 ± 5.9 0.563 −2.8 (−5.4, −0.2) 0.034
−0.10)
Sagittal angle (°) 1.9 ± 5.9 0.030 1.2 ± 7.3 0.300 0.7 (−2.1, 3.6) 0.604 2.5 ± 5.3 0.000 1.7 ± 8.6 0.201 1.7(−1.2, 4.7) 0.249
Vertical position (mm) 2.7 ± 1.5 0.000 1.7 ± 1.6 0.000 0.9 (0.3, 1.6) 0.003 3.2 ± 1.8 0.000 1.9 ± 1.9 0.000 1.2 (0.5, 2.0) 0.002
Canine cusp tip-dental arch plane (mm) −1.9 ± 1.5 0.000 −0.9 ± 1.7 0.002 −0.3 (−1.2, 0.6) 0.492 −0.5 ± 2.4 0.195 −0.1 ± 1.9 0.609 −1.1 (−1.8, −0.4) 0.001
Canine cusp apex-dental arch plane (mm) 0.2 ± 1.9 0.419 −0.1 ± 1.3 0.838 0.2 (−0.4, 0.8) 0.463 −0.6 ± 1.1 0.000 −0.0 ± 1.4 0.939 0.8 (0.2, 1.4) 0.012
Canine cusp tip-midline 2.3 ± 1.5 0.000 0.6 ± 1.9 0.037 1.7 (0.9, 2.5) 0.000 1.6 ± 1.6 0.000 0.7 ± 1.3 0.000 −0.62 (−1.1, −0.1) 0.017

Significant differences between and within the groups are given in P-values.
*P-value < 0.05 is considered statistically significant.

one group.

than male patients (23, 29, 33, 34).

indicate differences between T1–T0 and T1–T2.
(CG), respectively, with mean and P-values (**0.001 and *0.05). P-values
between T1–T0 and T1–T2 for the extraction group (EG) and control group
Figure  3.  Comparison of positional changes of the permanent canine

the overall stage of dental development of the child and not only the
capture PDCs at an early age. However, it is important to consider
12–13-year-old (36 per cent) patients (Table 1). A possible explana-
observations, the bilateral and unilateral PDCs were merged into
main outcome for the bilateral group was assessed as independent
7

studies on canine displacement, there was a larger number of female

in Sweden, all children at the age of 10 are strictly monitored to
in the age groups, with more 10–11-year-old (64 per cent) than
There was an uneven distribution of the number of patients

and chronological age (33). In accordance with other interceptive

chronological age because there is a poor correlation between dental
tion for the greater number of younger patients in this study is that,
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8 European Journal of Orthodontics, 2014
Table 5.  Root resorption of adjacent permanent teeth during T0–T2 expressed in amount of teeth (N) and % of teeth. CG, control group;
EG, extraction group
EG (N = 45 PDCs)
Grade 1
(no resorption) Grade 2 Grade 3 Grade 4
N % N % N % N %
T0 38 84.5 7 15.5 0 0
T1 38 84.5 7 15.5 0 0
T2 37 82.2 8 17.8 0 0
In a Cochrane systematic review that assessed the effect of
extracting the deciduous canine on the eruption of PDC, several
observations for what should be included in future studies were
discussed (25). The most important factors were concealed random
allocation, blind assessment, sample size, and correct statistical
analysis. We tried to fulfil these criteria in this study, but it was not
possible to blind the patients to the allocated intervention except
at baseline, where the radiographic measurements were blinded. It
was not possible to block out the deciduous canine space on the
radiographs on the 3D radiographs, as can easily be done on pano-
ramic x-ray. An alternative would have been an assessor who had no
knowledge of the study. This was not possible in this study, however,
as a new 3D measurement method to evaluate the canine position
had to be developed together with the oral radiologist (32).
In comparison with previously published studies where pano-
ramic x-ray were used for diagnosis of PDC and assessment of the
outcome, this trial is to our knowledge the first one to assess the
effect of extracting the deciduous canine in patients with PDC using
3D images. A more accurate diagnosis of the canine position and 3D
assessment of the canine movements are possible with 3D images. In
addition, small resorptions of the adjacent teeth caused by the PDC
can be detected.
Several RCT studies discuss the topic of interceptive treatment
of PDCs, both with and without a combination of different appli-
ances such as cervical headgear (HG) (34), rapid maxillary expan-
sion (RME) (35), RME followed by HG (36), extraction of both
the deciduous canine and the first deciduous molar (28), RME fol-
lowed by transpalatal arch (TPA) (27), extraction of the deciduous
canine followed by TPA (26), or extraction of the deciduous canine
on one side in patients with bilateral PDCs (29). These studies all
point toward the benefit of the interceptive treatment. However,
some weaknesses are noted, for example questionable power analy-
sis (26–28), questionable randomization, and the unequal descrip-
tive statistics at baseline between the different groups (26) and
missing allocation concealment concerning unilateral and bilateral
PDCs (26, 27), and uncertain diagnosing of PDC from only pano-
ramic radiography (28). The results of this study showed that sig-
nificantly (P  =  0.001) more canines erupted on the extraction site
(69 per cent) compared with the control site (39 per cent). These
findings are comparable and confirm the results of previous studies
that presented successful results between 62 and 67 per cent on the
extraction site and 28 and 42 per cent on the non-extraction site
(26, 29, 33, 34). Some studies present higher success rates of around
80 per cent (23, 28) or a lower success rate of 42 per cent (37). The
high success rate in the prospective uncontrolled study of Ericson
and Kurol (23) can be explained by that the authors having counted
both canine eruption and improvement of the canine eruption path
as a successful outcome. In the study by Bonetti et al. (28), patients
CG (N = 44 PDCs)
Grade 1
(no resorption) Grade 2 Grade 3 Grade 4
N % N % N % N %
37 84.0 7 16.0 0 0
34 77.3 10 22.7 0 0
31 70.5 13 29.5 0 0
with centrally placed canines together with PDC were included
and the CG was not randomized, which could have influenced the
results. The lower success rate found in the study of Smailienë et al.
(37) might be explained by the older age of the patients that were
included, as a higher age increases the probability of impactions.
Some previous studies (27, 28, 38) defined successful outcome as
fully erupted canines, thus permitting bracket positioning for final
arch alignment when needed or as defined by Bazargani et al. (29)
‘in an esthetical acceptable location in the dental arch’. This varia-
tion in definitions of successful outcome could be another reason for
the different success rates reported. In this clinical trial, canines that
emerged through the gingiva were considered successful. In addition,
in this study, only an ITT approach was used when the outcome was
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assessed, which may be another explanation for the differences in
the success rate.
Significantly more changes for both angular and distance vari-
ables were found between both T0–T1 and T1–T2 in the EG, which
was not surprising because the successful outcome was higher in the
EG than in the CG.
In the EG, the movement of the cusp-tip in relation to the den-
tal arch and in relation to the midline was larger during the first
6  months after extraction, while the movement of the apex was
larger between 6 and 12  months (Figure  3). These results support
Ericson and Kurol (23) finding that improvement of the position of
the PDCs can already be seen after 6 months.
The prognosis for successful orthodontic end results when adults
are treated for PDCs is poorer than in younger patients and the
prognosis worsens with age (1). Furthermore, the duration of ortho-
dontic treatment to address impacted canines correlated with age
in that the treatment duration increases with increased age (1, 39).
Permanent canines that have been impacted for many years undergo
pathological changes that prevent their eruption even when all other
factors are favourable (40). The risk for developing ankylosis either
a priori or during treatment is higher the older the patient is (40).
We, therefore, considered it unethical to follow-up patients longer
than 1 year without making any individual treatment plan, especially
as data from this study shows a tendency toward more resorbed
adjacent teeth in the CG at T2 than at T0 and as more canines had
erupted in the EG during the first 12 months. This was also the rea-
son for extracting the remaining deciduous canines in the CG that
were not mobile at T2.
The frequency of root resorption caused by PDCs has been
reported in the literature to be around 50 per cent of which the
majority are lateral incisors (41–44). In this study, however, 23.5
per cent showed resorptions, and only on lateral incisors. The low
figures may be explained by that this study comprise of prospec-
tive randomized design with the exclusion criteria: root resorption
of grades 3 and 4, while the above-mentioned studies either had a
J. Naoumova et al.
retrospective material or included only patients that were selected for
a CT imaging. Furthermore, the patients in this study were younger.
Ericson and Kurol (41) found that the peak frequency of root resorp-
tion is between 11 and 12 years of age. However, as the authors also
mention in their article, the selection and complexity of the material
including more severe cases might have affected the results.
The mean eruption time in the EG was shorter than in the CG
(15.6 versus 18.3 months). In total, 30 PDCs erupted after 12 months:
therefore, canines with an improved position after 1 year follow-up
should, therefore, be clinically and, if necessary, radiographically fol-
lowed up as spontaneous eruption after 12 months is still possible.
Ten of 30 PDCs that erupted after 12 months were in the CG, while
five deciduous canines were extracted at T2, as these canines were
not mobile. If these five extracted deciduous canines are excluded,
the mean eruption time in the CG increased to 19.3 ± 4.7 months.
According to this study, early diagnosis of PDCs and extrac-
tion of the deciduous canine as an interceptive approach is recom-
mended. The protocol with systematic use of CBCT in this trial was
designed so as to make it possible to draw out the results. However,
for everyday diagnostics and follow-up of uneventful cases of lost
canines, we suggest the use of 2D imaging. Furthermore, as some
permanent canines erupt without extracting the deciduous canine
first and some permanent canines do not erupt in spite of extraction
(See online supplementary figure 2), the question arises as to whether
it is possible to distinguish these cases. Thus, unnecessary intercep-
tive extractions may be avoided or perhaps a decision in favour of
surgical exposure of the impacted canine immediately without pre-
ceding interceptive extraction of the deciduous canine can be made.
Because extraction of the deciduous canine or surgical exposure
might be the child’s first experience of invasive dental treatment, it
is important that the child does not develop dental fear as a conse-
quence of the intervention. Although Naoumova et al. (45) showed
that the experience of pain and discomfort during and after extraction
of the deciduous canine in patients with PDC was low, 42 per cent
of the children in their study nevertheless used analgesics, indicating
post-extraction pain. Therefore, some surgical interventions may be
avoided by predicting and calculating cut-off points for a successful
outcome. A  more detailed determination of predictors and cut-off
points for successful outcome will be analysed in part II of this study.
Limitations
As no CBCT’s were taken, for ethical reasons, of the PDCs that
were erupted at T2, imputation values were used as an alternative
of excluding these cases. Using the imputation values instead of con-
sidering these patients as dropouts is, in our opinion, an advantage,
as those teeth that had erupted spontaneously probably are those in
“best” position and excluding them would have biased the results.
However, as imputation values of normally erupting canines at T2,
from the unilateral patient group were used in 15 patients, this
might have affected the results of the angular and positional changes
between T1 and T2. To find out how the results might change using
imputation values of normally positioned canines, a comparison
was made between the imputed values and values from the bilateral
patient group that had one PDC under eruption while the other was
still palatally displaced i.e. x-rays were taken at T2. Seven spontane-
ously erupting PDCs were identified and compared. No significant
differences were found either for the angular or for the positional
changes between the erupted PDCs and those with normal position.
However, an imputation can always give uncertainty in the results,
therefore the changes between T1 and T2 should be interpreted with
some caution.
9
Generalization
The results of the main sample obtained from the present sample can be
generalized only in a Caucasian population aged 10-13 years and in the
case that the exclusion criteria are met. The use of imputation values as
mentioned above, may curtail the generalization of the results regarding
the positional changes of the canine between T1 and T2. In addition, due
to the selective exclusion of PDCs resorbing adjacent teeth with grades
3 and 4 at the start and during the trial, may limit its representative-
ness, and thus limit the generalization of the frequence of root resorption
caused by PDCs in a general population.
Conclusions
• Extraction of the deciduous canine in patients with PDC is an
effective interceptive approach: 69 per cent of the permanent
canines erupted when the deciduous canine was extracted, while
39 per cent erupted in the non-EG. The mean eruption time was
15.6 months in the EG and 18.3 months in the CG.
• Significantly more angular and distance changes occurred in the
EG compared with the CG.
• In the EG, the movement of the cusp-tip in relation to the dental
arch and in relation to the midline was larger during the first
6  months after extraction, while the movement of apex was
larger between 6 and 12 months.
• Canines with an improved position at the 12  month control
should be followed up with a clinical and if necessary a radio-
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graphic examination, as spontaneous eruption after 12 months
still is possible.
• No significant differences in root resorption of adjacent teeth
was found at T2 between the CG and the EG.
Supplementary material
Supplementary material is available at European Journal of
Orthodontics online.
Funding
Local Research and Development Board for Gothenburg and Södra
Bohuslän; Health and Medical Care Committee of the Regional
Executive Board for Västra Götaland Region.
Acknowledgements
This work is dedicated to Prof. Jüri Kurol who suddenly and sadly passed away
during the work of this study. The authors wish to thank the general practi-
tioners and the consulting orthodontists at the Department of Orthodontics,
University Clinics of Odontology, Gothenburg, Sweden, for identifying and
inviting potential patients to participate in the study.
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