To cite this article: Sharma VK, et al.

Variables to predict spontaneous eruption of palatally displaced permanent canine after

interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
International Orthodontics 2020; //: ///

Websites:
www.em-consulte.com
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Systematic review and meta-analysis

Variables to predict spontaneous eruption
of palatally displaced permanent canine
after interceptive extraction of primary
canine: A systematic review and meta-
analysis

Vipul Kumar Sharma, Neeteesh Kumar Shukla, Thakur P. Chaturvedi, Sneha Singh
Available online:

Banaras Hindu University, Department of Orthodontics, FODS, IMS, Varanasi, UP, India

Correspondence:
Neeteesh Kumar Shukla, Banaras Hindu University, Department of Orthodontics,
FODS, Trauma center campus, IMS, Varanasi, UP, 221005, India.
nksindian@gmail.com

Keywords Summary
Palatally displaced canine
Interceptive extraction Objective > To evaluate the effectiveness of different diagnostic variables measured on panoramic
Spontaneous eruption radiographs (PAN) to predict spontaneous eruption of palatally displaced canine (PDC) after
Radiographic predictors interceptive extraction in late mixed dentition.
Alpha angulation Materials and Methods > Digital databases (MEDLINE, CENTRAL (Cochrane), Scopus, clinicaltrials.
gov, ISRCTN registry) and hand searches were performed up to March 2020. Both randomized and
non-randomized controlled trials were considered for the review. Study selection, data extraction,
risk of bias assessment (RoB2.0 and ROBINS-I), and the certainty of evidence evaluation (GRADE)
were performed according to Cochrane Handbook for Systematic Reviews of Interventions. The
random-effects method for quantitative synthesis of dichotomous as well as continuous data was
used.
Results > Out of 767 retrieved records, 4 controlled trials fulfilled the eligibility criteria and were
included in the review. Studies were assessed at low risk of bias except one. Overall certainty was
strong to moderate. PDCs in distal sectors (RR: 1.621; 95%CI: 1.259 to 2.086; P < 0.001) and alpha-
angle < 308 (SMD: 1.350; 95%CI: 1.924 to 0.776; P < 0.001) were significantly benefited from
interceptive extraction. However, Vertical distance of PDC cusp tip from occlusal plane had
statistically insignificant (p: 0.855) roll on eruption prediction.
Conclusion > Interceptive extraction at a younger age, initial horizontal localization (sector posi-
tion), and alpha-angle (initial mesial inclination) are the most important variables predicting the
spontaneous eruption of palatally displaced canines. Findings of this review can be utilized to
make evidence-based decisions for managing PDCs with diverse sectors and mesial inclinations.
However, well designed clinical trials are recommended to strengthen the evidence.

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1

https://doi.org/10.1016/j.ortho.2020.11.004
© 2020 CEO. Published by Elsevier Masson SAS. All rights reserved.

ORTHO-526
 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004

V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh

Systematic review and meta-analysis

also been identified in several studies [1–6,11–15]. Recently,

Glossary researchers tried to figure out possible predictors of success
PAN Panoramic radiograph and cut-off points to benefit from extraction of the deciduous
PDC Palatally displaced canine
CBCT Cone beam computed tomography
canine using PAN and CBCT (cone beam computed tomography)
GRADE Grading of Recommendations Assessment, Development and [6,11]. Although prediction of successful eruption of PDC based
Evaluation on the position of the displaced maxillary canine has been
PICOS Participants Interventions Comparisons Outcome Study
design
described in several literatures [1–6,11–15], none of the pub-
RCT Randomized clinical trial lished studies performed a systematic review and meta-analysis
NRIS Non-randomized intervention study to investigate the quality of evidence and effectiveness of dif-
RR Relative risk
RD Risk difference
ferent predictive variables. The primary aim of this meta-analysis
SMD Standardized mean difference is to establish which possible predictors based on position of
CI Confidence interval displaced canines identified in a panoramic radiograph would
facilitate the eruption of PDC, when considering interceptive
extraction of primary canines in late mixed dentition.

Introduction Materials and methods

It is well known that management of a palatally displaced canine
(PDC) involves either an interceptive approach in mixed dentition
or a corrective form of treatment later during permanent denti-
tion. A corrective treatment procedure embraces surgically
assisted orthodontic traction to facilitate the guided eruption
of the impacted canine. Proper management protocol, predic-
tions to have a sound prognosis and conscious consideration of
biomechanical aspects are important to prevent risk and compli-
cations arise due to surgically assisted orthodontic management.
Timely diagnosis of palatal displacement of a canine along with
the prediction of subsequent impaction is crucial to lessen the
patient's need for surgically assisted orthodontic procedure.
Spontaneous eruption of a displaced canine is possible by inter-
ception at late mixed dentition via different interceptive treat-
ment alternatives which primarily involve extraction of primary
predecessors or space gaining methods [1–7].
Systematic reviews and meta-analysis have been done previ-
ously to provide the evidence regarding effectiveness of inter-
ceptive extraction of primary canines for spontaneous eruption of
PDC [8–10]. Moreover, different radiographic predictors (mesio-
distal canine crown position in sectors, mesial inclination of PDC
to midline, vertical distance of canine cusp-tip to occlusal plane
etc.) of successful eruption of PDCs following interception have
We followed PRISMA (preferred reporting items for systematic
reviews and meta-analysis) guidelines (www.
prisma-statement.org) and the Cochrane Handbook for System-
atic Reviews of Interventions (www.cochrane-handbook.org)
for the proper conduction and reporting of the analysis [16,17].
Information sources and search Strategy
Unrestricted electronic and manual searches were performed up
to March 2020. Published literature and abstracts were retrieved
by digital databases including MEDLINE via PubMed (www.ncbi.
nlm.nih.gov), the Cochrane Collaboration Oral Health Group
Database of Clinical Trials (www.cochrane.org), and Scopus
(http://www.scopus.com), along with other sources like Clini-
cal trial registry (ISRCTN registry) and Clinicaltrials.gov. Database
specific terms and free text keywords were used to identify
published literature.
Eligibility criteria
Table I explains the eligibility criteria based on populations,
interventions, comparisons, outcomes, and study designs
(PICOS). All four authors independently assessed all article
abstracts that appeared to meet the inclusion criteria. Any
conflicts among reviewers were resolved by discussion to reach
a final agreement.

TABLE I
Eligibility Criteria (PICOS).

Domains Inclusion criteria Exclusion criteria

Participants Subjects in the mixed dentition; Subjects with craniofacial anomalies orsyndromes of the
Male/female; head and neck region;
Any race or ethnicity; Studies of adults or participants with previous
2

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
Variables to predict spontaneous eruption of palatally displaced permanent canine after interceptive extraction
of primary canine: A systematic review and meta-analysis

Systematic review and meta-analysis

TABLE I (Continued).

Domains Inclusion criteria Exclusion criteria

Presence of palatally displaced permanent canines orthodontic treatment;
(PDCs)- unilateral or bilateral. Studies involving children with primary dentition.

Intervention Interceptive extraction of deciduous maxillary canines in Studies of interceptive treatment without a control
late mixed dentition period with or without other group;
interceptive approach. Studies evaluating surgical exposure of PDCs;
Other interceptive treatments except primary canine
extraction.

Comparison Evaluation of eruption of PDC under the influence of
variation in sectors, angles, vertical distance identified in
PAN, age, sex, skeletal maturation, root development,
and unilateral or bilateral occurrence of PDCs.
Articles evaluating improvement in intra- osseous
position of displaced palatal canine without concluding
predictors for spontaneous eruption; Studies comparing
extraction of primary maxillary canine or canines to
alternative interceptive approaches.

Outcome Percentage of successful outcome. i.e. the prevalence of
spontaneous eruption of PDCs in the dental arch due to
variation in canine crown position (sector, angles,
distance), skeletal maturation stage, root developmental
stage. No restrictions were made to analyze other
possible outcomes reported in included studies.
Study design Randomized clinical trials, prospective controlled trials
with at least 12 months of observation period after the
intervention
Successful outcome due to extraction of primary canine
but no conclusion about predictive variables regarding
spontaneous eruption of PDCs.
Review articles, retrospective studies, studies without
control groups, case reports, and case series. Animal
studies. Systematic reviews and meta-analyses

Study selection, data collection and analyses
Two reviewers (NKS and VKS) screened titles and abstracts of
electronically retrieved records for inclusion. Subsequently, the
literature that met the eligibility criteria were studied fully and
again judged against inclusion and exclusion criteria. Disagree-
ments were resolved by discussion with the third (TPC) and
fourth author (SS). Data extraction was obtained independently
by the same two reviewers and any conflicts were again
resolved by consultation with the third and fourth author. The
following information was extracted: authors, year of publica-
tions, radiographs used, interventions, variables measured, age
of participants, number of participants and dropouts, duration of
follow-up, outcomes, and conclusion. Each author indepen-
dently assessed the methodological soundness and quality of
included literature.
Risk of bias across studies and additional analyses
Two authors (NKS and SS) assessed the risk of bias in individual
studies using the recent modified Risk of Bias assessment tool
(RoB 2.0) for randomized clinical trials (RCTs) and ROBINS-I for
non-randomised intervention studies- NRISs (https://www.
riskofbias.info/welcome/rob-2-0-tool and https://www.
riskofbias.info/welcome/home/current-version-of-robins-i
accessed April 6, 2020; current version) [18,19]. Any
disagreements were resolved by discussion with other two
authors (TPC and VKS). An online web app robvis was used for
visualizing the risk of bias assessments as "traffic-light'' and
"weighted-bar'' plots (https://www.riskofbias.info/welcome/
robvis- visualization-tool) [20]. Analyses were planned to rule
out 'small-study-effects' and publication bias if a required num-
ber of studies were identified [17]. Finally, the quality of available
evidence was assessed based on the Grades of Recommenda-
tion, Assessment, Development, and Evaluation (GRADE)
approach (http://www.gradeworkinggroup.org) [21].
Summary measures and synthesis of results
Studies were considered for quantitative analysis if presented
with sufficient homogenous data with respect to intervention
and outcomes. Otherwise, qualitative assessment of the data
would have been undertaken. Data on the successful eruption of
PDC in the dental arch due to variation in canine crown position
and other possible factors were expressed as risk ratios (RR) for
dichotomous and standardized mean difference (SMD) for con-
tinuous data, together with the 95% confidence intervals (CI). In
order to have a measure of the absolute risk, data were also
expressed as risk difference (RD) together with 95% CI. As the
studies differ in terms of participant groups, settings, proce-
dures, and follow-ups, the random-effects-model for meta-
3

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh
Systematic review and meta-analysis
analysis was used to combine the data. Between-study hetero-
geneity was quantified using I2 statistic. The level of significance
was set at 0.05, except for the 0.10 used for the heterogeneity
tests. All analyses were done with Comprehensive-Meta-Analy-
sis V.3.0.70 (Biostat Inc, Englewood, NJ, USA)
Results
Study Selection
Electronic searches were done according to database specific
guidelines using a combination of search terms. The established
database search strategy is explained in supplementary table I.
Steps taken during the reviewing process to identification and
selection of studies are presented in figure 1. We initially
identified 767 records, in which 233 were excluded as dupli-
cates. 522 more articles were rejected on the basis of titles and
abstracts. Subsequently, full text assessments were done on the
remaining 12 records for eligibility, 8 studies [1,2,7,12,13,
15,22,23] were excluded with reasons given in supplementary
table II. Finally, 4 full-text controlled trials (3RCTs and 1 NRIS)
were included in the systematic review. References and
citations of final included articles were also explored for any
relevant studies.
Figure 1
PRISMA flow diagram
4
Study Characteristics
Information extracted from the included studies is summarized in
tables II and III. The articles were published between 2011 and
2018. Total 428 PDCs were identified in 278 subjects. No statistically
significant difference was reported with regard to gender and age
in baseline data. Interceptive extraction was performed during the
mean age of 10.93yrs  11.4 m and patients were followed for a
period of minimum 12 months to maximum 3 years 7 months. In
addition, all 4 included studies, performing the any particular type
of interception coupled with deciduous extraction and considered
inspecting the accuracy of the measurements checked out in some
way. The proportion of successful eruption in the treatment group
was reported to be minimum 65.2% to maximum 80%. In addition,
diagnostic variables were taken and measured on the PAN accord-
ing to the method first described by Ericson and Kurol [1]: sector,
mesiodistal-crown position in sectors 1–5 (sectors 1–2 distal to and
sectors 3-4-5 mesial to long axis of root of erupted adjacent lateral
incisor); alpha-angle, an angle formed by the long axis of the
canine and the midline; Vertical distance, distance in mm from the
canine cusp-tip to the occlusal plane. Cervical vertebrae maturation
stage (CS) was assessed according to a method proposed by
Baccetti et al., 2005 [24]. Root development of PDC was evaluated
according to Nolla-stages [25].
tome xx > 000 > xx 2020
 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
Variables to predict spontaneous eruption of palatally displaced permanent canine after interceptive extraction
of primary canine: A systematic review and meta-analysis

Systematic review and meta-analysis

TABLE II
Characteristics of included studies.

Authors Study Design Definition of PDC Radiographs Intervention Variables Additional information
measured in
radiographs
Baccetti T et al. Randomized Not mentioned PAN and lateral RME/TPA/EC (TG1) Sectors (1–5) Priori sample calculation: Yes;
2011 [3] Clinical Trials cephalogram group, Alpha angles Comparison of baseline data
Italy TPA/EC (TG2) Vertical distance among groups: Yes; Accuracy
group, CS stage, of measurement considered:
EC (TG3) group Nolla stages of Yes; Definition of successful
root development eruption of canine: Yes

Sigler LM et al. 2-center Not mentioned PAN and lateral RME followed by Sectors (1–5) Priori sample calculation:No;
2011 [4] prospective cephalogram TPA coupled with Alpha angles Comparison of baseline data
Italy longitudinal extraction of the Vertical distance between groups: Yes;
clinical trail deciduous canine CS stage, Accuracy of measurement
(NRSI) Nolla stages of considered: Yes; Definition of
root development successful eruption of canine:
Yes

Bazargani F et al. Randomized Not mentioned PAN and occlusal Extraction of Sectors (1–5) Priori sample calculation:Yes;
2014 [5] Clinical Trials radiographs Deciduous canine Alpha angles Comparison of baseline data
Sweden Vertical distance between groups: Yes;
Accuracy of measurement
considered: Yes; Definition of
successful eruption of canine:
Yes

Naoumova J et al. Randomized Not mentioned PAN Extraction of Sectors (1–5) Priori sample calculation:Yes;
2018 [6] Clinical Trials Deciduous canine Alpha angles Comparison of baseline data
Sweden Vertical distance between groups: Yes;
Nolla stages of Accuracy of measurement
root development considered: Yes; Definition of
successful eruption of canine:
Yes

NRSI: Nonrandomized study of intervention; PAN: panoramic radiograph; RME: rapid maxillary expansion; TPA: transpalatal arch; EC: extraction of primary canine; TG: treatment
group; CS: cervical stage of skeletal maturation.

TABLE III
Characteristics of study participants and outcome.

Authors Mean age of Participants no. Duration of Spontaneous Outcome Predictors

participants and dropouts Follow-up eruption of PDCs concluded

Baccetti T et al. TG1-10y5 m TG1–40 (25F TG1-3y 6 m TG1-80% Successful vs Interceptive

2011 [3]  10 m + 15 M: 66 PDCs)  16 m TG2-79% unsuccessful cases treatment/
Italy TG2-10y9 m TG2-24 (14F TG2-2y 9 m TG3-62.5% (treated group) Extraction of
 11 m + 10 M: 36 PDCs)  13 m CG-28% Alpha anglec, primary canine;
TG3-11y1 m TG3- 24(14F TG3-2y 2 m Vertical distance: Pre-pubertal stage;
 11 m + 10 M: 34 PDCs)  10 m NS Less advanced
CG-10y5 m  10 m CG-29 (18F + 11 M: CG-3y 1 m  14 m Sectorc, sector;
42PDCs) CSc Smaller alpha
3 dropouts- one in RPDC angle;
each of the TG2, UL vs BL PDC: NS Less advanced root
TG3 and CG development
5

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004

V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh

Systematic review and meta-analysis

TABLE III (Continued).

Authors Mean age of Participants no. Duration of Spontaneous Outcome Predictors

participants and dropouts Follow-up eruption of PDCs concluded
Sigler LM et al. TG and CG- TG–40 (25 F TG-3y 7 m W 17 m TG-80% Successful vs Interceptive
2011 [4] 10y5m W 10 m + 15 M: 65PDCs) CG-3y 1 m W 14 m CG-28% unsuccessful cases treatment/
Italy CG–30 (18 F (treated group) Extraction of
+ 12 M: 48 PDCs). Alpha angle: NS primary canine;
Dropouts-1 in each Vertical distance: Pre-pubertal stage;
TG/CG NS Less advanced
Sectorc, sector;
CSc Less advanced root
RPDC development
UL vs BL PDC: NS
Bazargani F et al. TG and CG 48 PDCs in 24 6 months interval TG-67% Agea No direct
2014 [5] 11y6m W 14 m (8M + 16F) for 18 months CG-42% Observed conclusion was
Sweden subjects tendency for a made regarding
TG–24 PDCs weaker predictors except
CG–24 PDCs response of the Interceptive
No dropouts PDCs in the higher extraction and
zones (4 and 5) younger age;
compared to the One more variable
PDCs in the lower concluded from
zones (2 and 3). data available:
Less advanced
sector (zone)

Naoumova J et al. TG and CG 67 subjects with 24 months TG-69% Successful vs. Interceptive
2018 [6] 11y4m W 12 m 89 PDCs (27M CG-39% unsuccessful cases extraction
Sweden + 40F) (treated group) Smaller Alpha
TG-46 PDCs Alpha anglec, angle
CG-43 PDCs Vertical distance: Less advanced
No dropouts NS sector
Sectorb, Younger patients
RPDC Less advanced root
Agec development

TG: treatment group; CG: control group; PDC: palatally displaced canine; m: months; y: year; NS: not significant; CS: skeletal maturation cervical stage; RPDC: less advanced root
development of PDC in success Vs unsuccessful cases; UL: unilateral PDC; BL: bilateral PDC.
a
P < 0.05.
b
P < 0.00.
c
P < 0.001.

Results of individual studies and data synthesis
Predictive variables of spontaneous eruption following
interceptive extraction.
Data availability in respective studies and quantitative analysis
results (expressed as RR and RD for dichotomous data; and SMD
for continuous data) are given in supplementary Table III. There
were no PDCs located in sector 1 or 5 as identified in two studies
[5,6]. Almost 100% success rate was calculated for sector 1, 89%
for sector 2, 59% for sector 3, and 32% for sectors 4–5. Similarly,
success rate for cervical stages concluded from pooled data was
92.5% in CS1, 85% in CS2, 57% in CS3, and 0% in CS4. Mean
alpha-angle in successful cases was 25.96  5.30 while in
6
unsuccessful cases it was 33  7.270. Meta-analysis of pooled
data shows statistically significant results for spontaneous erup-
tion when PDCs were located in distal sectors (sectors 1–2 com-
pared to sectors 3-4-5- RR: 1.621; CI: 1.259 to 2.086; P < 0.001; I2:
15.641%; sector 2 compared to sector 3- RR: 1.465; CI: 1.174 to
1.829; P < 0.001; I2: 0%; sectors 2–3 compared to sectors 4-5- RR:
2.211; CI: 1.206–4.054, P < 0.01; I2: 0%; figure 2-2.1, 2.2, 2.3
respectively), mean alpha angulation appeared to be <300 (SMD:
1.350; SE: 0.293; CI: 1.924 to 0.776; P < 0.001; I2: 53.751%;
figure 3-3.1), and when interceptive extraction was performed at
prepubertal stage CS1-2 compared to pubertal stage CS3-4 (RR:
1.658; CI: 1.197–2.296; P < 0.005; I2: 0%). Furthermore, all the

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
Variables to predict spontaneous eruption of palatally displaced permanent canine after interceptive extraction
of primary canine: A systematic review and meta-analysis

Systematic review and meta-analysis

Figure 2
Forest plot presentation of Sectors 1-2 Vs Sectors 3-4-5 (2.1), Sector 2 Vs Sector 3 (2.2), Sectors 2-3 Vs Sectors 4-5 (2.3)

included studies provided data about the effectiveness of inter-
ception compared to no treatment. 73% PDCs were successfully
erupted in intervention groups while only 34% in non-extraction
groups. The result was statistically significant favouring sponta-
neous eruption following interception (RR: 2.086; CI: 1.578–
2.758; P < 0.001; I2: 9.571%; figure 3-3.2). Contrary to above,
statistically significant difference was not found regarding verti-
cal distance from PDC cusp-tip to occlusal plane (SMD: 0.033; SE:
0.181; CI: 0.322 to 0.388; p > 0.05; I2: 4.590%; figure 4-4.1).
Mean vertical distance in successful cases was 16.16  3.39 mm
while in unsuccessful it was 16.4  2.67 mm obtained from
pooled data. Similarly, results were insignificant for PDCs located
in sector 3 compared to sectors 4–5 (RR: 1.637; CI: 0.849 to 3.158;
P > 0.05; I2: 0%; figure 4-4.2), and for occurrence of unilateral or
bilateral PDCs (RR: 0.99; CI: 0.811 to 1.213; P > 0.05; I2: 0%). In
addition, it was noted that none of the treated groups in analysed
studies had a mean alpha-angle < 200 and vertical distance
< 10 mm or > 20 mm.
7

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004

V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh

Systematic review and meta-analysis

Figure 3
Forest plot presentation of Alpha angulation (3.1) and Interception Vs no interception (3.2)

Figure 4
Forest plot presentation of Vertical distance (4.1) and Sector 3 Vs Sectors 4-5 (4.2)

Other reported outcome (Nolla-stages > 8) of treated subjects. Response to interception

Three studies [3,4,6] reported less advanced root development in younger age was more than the older age group as concluded
(Nolla-stages  8) in erupted groups than in unerupted groups from 2 studies [5,6] in which one study [6] mentioned mean age
8

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
Variables to predict spontaneous eruption of palatally displaced permanent canine after interceptive extraction
of primary canine: A systematic review and meta-analysis

Systematic review and meta-analysis

of the patient in successful cases of extraction group was 11yrs
 0.9yrs while in unsuccessful cases it was 12 yrs  1.0yrs
(P < 0.001). In addition, side effects of interceptive extraction
were also concluded, one was significant space changes of about
1 mm (P: 0.010) and others were minor midline shifts in the
maxilla, rotation or movement into the extraction site. Two
studies [4,6] reported significant prevalence of dental deviations
in subjects with PDCs. Common dental anomalies noted are small
lateral incisors (narrow lateral incisor crown, malformed roots),
eruptional deviations (ectopic eruption of premolars and can-
ines), infraocclusion of deciduous molars, agenesis of the second
premolars, invaginations, and taurodontic molars.
Spontaneous eruption without prior deciduous canine
extraction
Two studies [4,6] mentioned data on the variables affecting
successful eruptions in control groups. Success rate reported in
sector 1 was 75% (1 study) [4]. Furthermore, 41.6% PDCs in sector
2 and only 11% in sectors 3-4-5 were erupted successfully
(2 studies) [4,6]. Therefore, for spontaneous eruption without
prior extraction it was essential that the PDCs were located initially
in sector 1. In addition, mean angulation reported in successful
cases of untreated group was 19.7  4.60 (P < 0.01). It was noted
that Nolla-stages of root development of PDCs and mean age of
untreated groups were slightly lower than treated groups. In
contrast, no significant differences were noted regarding vertical
distance, and the occurrence of unilateral or bilateral PDCs.
Risk of bias and additional analyses
Findings regarding risk of bias assessment in RCTs are summa-
rized in supplementary table IV, and summary plots are given in
figure 5 while risk of bias assessment in NRIS is explained in
table IV, Three studies [4–6] were classified as being at low risk
of bias in which two were assessed by RoB 2.0 (RCT) and one
was assessed by ROBINS-I tool (NRIS). One RCT was considered
to be at high risk of bias presented with general shortcomings

Figure 5
Traffic light plot and weighted plot summary of risk of bias of RCTs

TABLE IV
Risk of Bias Assessment in NRISa (ROBINS I).

Preintervention Intervention Postintervention

Study Bias due to Selection of Classification of Deviation Missing Outcome Selection of Overall
confounding the participant intervention from intended data assessment the reported
into the study intervention result
Sigler LM et al. Low Low Low Lowb Low NI (Low)c Low Low risk bias
2011 [4]
a
Non-randomized study of intervention.
b
Blinding was not possible due to type of intervention used, reviewers discussed and agreed that results are not likely to be affected by lack of blinding.
c
NI: no information that the investigator was blinded with regards to assessments. However, reviewers believe that outcome is not likely to be influenced by lack of blinding.
9

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 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004

V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh

Systematic review and meta-analysis

TABLE V
GRADE approach for certainty of evidence assessment (low risk of bias studies).

Assessment (Design) Risk of bias Inconsistency Indirectness Imprecision Other Impact on successful Certainty
eruption of PDC
Sector variation Not serious Not serious Seriousb Not serious None PDCs in distal sectors favors O Moderate
2 RCTs +1NRISa spontaneous eruption; Pd
Alpha angulation Not Serious Not serious Not serious Seriousc None Initial alpha-angles < 300 O Moderate
1 RCTs +1NRISa favors spontaneous eruption;
Pd
Vertical distance Not Serious Not serious Not serious Seriousc None Initial vertical distance had no O Moderate
1 RCTs +1NRISa impact on successful eruption
of PDC; Pe
Skeletal maturation Not Serious Not serious Not serious Seriousc None Interception at prepubertal O Moderate
1NRISa stage favors successful
eruption of PDC; Pf
Root development of PDC Not Serious Not serious Not serious Seriousc None Erupted PDCs had less O Moderate
1 RCTs +1NRISa advanced root development
Interceptive extraction Not Serious Not serious Not serious Not serious None Favors successful eruption of  Strong
2 RCTs +1NRISa PDC; Pd
Unilateral Vs Bilateral PDC Not Serious Not serious Not serious Seriousc None Not significant; Pe O Moderate
1NRISa
Age of the participant Not serious Not serious Not serious Seriousc None (younger age10–12y); Pd O Moderate
2 RCTs
a
Low risk bias, properly conducted non-randomized study considered equivalent to a well conducted RCT, no further attempts were made to lower the level of evidence
b
Indirect evidence regarding sector variation was provided by one RCT
c
Number of cases studied was limited
d
P < 0.001.
e
P < 0.05.
f
P < 0.005.

owing to conduction and reporting of the study [3]. It was not
possible to conduct analyses for 'small-study-effects' and publi-
cation bias because an insufficient number of studies were
retrieved. The quality of evidence was evaluated according to
GRADE approach given in table V, performed only for low risk
bias studies because study with high risk bias presented with
various shortcomings. Certainty was concluded as strong for
effectiveness of interceptive procedure and moderate for all
other outcomes regarding eruption of PDC.
Discussion
Although interceptive extraction of primary canines is beneficial
for spontaneous eruption of PDCs, it has been shown in con-
cluded data of previous studies that even after the said inter-
ception, not all canines erupt spontaneously [8–10]. Since
success is not absolute for spontaneous eruption, many studies
identified the possible predictors by which effectiveness of
interceptive extraction can be predicted [1–6,11–15,26,27].
Focus of this systematic review was also to conclude the possi-
ble predictors for spontaneous eruption. Researchers utilized
both 2D (PAN, Lateral cephalogram etc.) [1–6,12–15,27] as well
as 3D imaging like CBCT [11,26] for the retrieval of predictors.
Moreover, PAN is frequently utilized in orthodontic practice and
10
an acceptable substitute for CBCT for predicting the outcomes as
stated by Naoumova et al. [6]. We included studies in which the
variables were measured on PAN because most of the previous
studies [1–6,12–15,28,29] used PAN radiographs for the evalua-
tion purpose using a method developed by Ericson and Kurol [1].
This systematic review and meta-analysis shows statistically
significant data that both the alpha-angle and sector evaluation
on panoramic radiograph can be considered as good prognostic
variables of whether the PDC will erupt spontaneously or not.
This is in unison with the other studies [1–3,6,13], while few
studies reported that the pre-treatment alpha-angle was not
associated with a favourable outcome [4,15]. According to some
studies mesio-distal crown position of PDCs in sectors was the
single most important predictive variable [4,14,15], but accord-
ing to present analyses, both the alpha-angle and sectors have
comparably good prognostic values. Canine crown located in
different sectors have been statistically compared in this review
to get an idea about positional variation and its influence on
spontaneous eruption. Our findings show that if PDC does not
cross the long axis of root of erupted adjacent lateral incisor,
chance for spontaneous eruption will be significant following
interceptive extraction or in other words, chance of impaction is
greater when PDC cusp-tip travels into sector 3 or beyond. These

tome xx > 000 > xx 2020

 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
Variables to predict spontaneous eruption of palatally displaced permanent canine after interceptive extraction
of primary canine: A systematic review and meta-analysis
findings are in accordance with a study in which the greatest
probability of impaction was found in sectors 3 (0.87) and 4
(0.99) [15]. Moreover, in sector 1 almost all displaced canines
erupted successfully which is also in accordance with previous
studies [6,15] facilitating the point raised by Naoumova et al.,
2018 [6], whether canines in sector 1 should be considered as
PDCs or with normal eruption. An alpha-angle < 300 was found
to be associated with a chance of successful eruption, which has
also been reported previously [2–4,6]. Some literature reported
vertical distance from the canine tip to occlusal plane as an
additional predictor for favourable eruption of PDC [12,13], a
finding that is neither in accordance with earlier studies [1–4,6]
nor with ours.
Interceptive extraction of deciduous canines is rewarding if
performed at the prepubertal stage (CS1-2), a finding that is
supported by other studies [3,4]. Furthermore, unerupted PDCs
had significantly advanced root development than in success-
fully erupted PDCs. Similar results have been shown in other
studies [3,4,6]. Spontaneous eruption of PDC has nothing to do
with unilateral or bilateral occurrence of PDCs as also identified
in other reports [4,6]. The findings of our review regarding
dental anomalies were largely identical to previous articles
and supporting the theory of the multifactorial aetiology having
a genetic control [4,6,30–32]. It was observed in previous studies
[4,6] as well as in this present review, spontaneous eruption of
PDC without interceptive extraction was possible when PDC
located initially in distal sectors (sector 1, and less commonly
in sector 2), having a mean alpha-angle < 200. In addition,
patients were younger and observed with less advanced root
development than extraction groups.
Recommendation and future research
Our recommendation is to use the predictors presented in this
article as guidelines to decide whether an interceptive extrac-
tion should be performed or not. Interceptive extraction is most
likely to be beneficial when performed during the prepubertal
stage in a subject having less advanced root development of PDC
with an alpha-angle of < 300, located in sectors 1–2. Unneces-
sary interception, waiting, and observation could most likely be
avoided in PDC cases with alpha-angle > 300, located in sector
4–5. Although in sector 3 statistically significant eruptions were
not found compared to sectors 1–2, still notable number of PDCs
(59%) erupted successfully indicating the possibility of other
factors acting simultaneously for success in this particular sector.
As none of the included literature studied the effect of smaller
alpha-angle (< 200) or distance (< 10 mm) on spontaneous
eruption of PDC if located in sector 3, this may be a viable topic
for future research considering relevancy of reviewed clinical
issue. In addition, an adequate follow-up period of approxi-
mately 12 months is recommended instead of less than this
because most of the studies showed that the majority of the
permanent canines erupted after 12 months.
tome xx > 000 > xx 2020
Systematic review and meta-analysis
Strength and Limitations
We followed well-established guidelines for conduction and
reporting of this present review. This review is a sincere attempt
to provide the evidence regarding a clinically relevant issue in
orthodontic practice. In addition, a genuine attempt was made
to perform clear and unimpeded searches for all possible and
worthy studies, undertaken with thorough data on the review
outcomes.
There are some limitations to the present review mainly due to
the limited number of studies retrieved in which one RCT
presented with high risk bias and methodological shortcomings.
Another limitation is due to data combined from the limited
number of cases finally analyzed resulting in imprecision of the
effect estimates. There are limitations to generalizability of our
results to other population groups because included studies
were carried out in Italy (2 studies) and Sweden (2 studies)
and recruited subjects of white antecedents only. Therefore,
high-quality randomized clinical trials to investigate the same
issue involving different population groups are necessary. In
addition, an evaluation of the side effects of the interceptive
method, patient related outcomes, and its associated economi-
cal assessment should also be carried out.
Conclusion
Interceptive extraction of primary canines is the variable most
affecting the eruption of PDCs.
Sector location and alpha angulation measured on a panoramic
radiograph are equally important variables to predict the suc-
cessful eruption or eventual impaction of PDCs in extraction as
well as non-extraction groups.
Interceptive extraction is beneficial to perform in younger age
groups particularly during the prepubertal stage of skeletal
maturation and when root of PDC is still developing.
However, more low risk of bias studies with sound methodo-
logical quality are needed to reinforce the conclusive evidence,
and indubitably guide clinical decisions.
Acknowledgements: None.
Funding: none.
Ethics approval and consent to participate: ethical approval was not
required.
Consent for publication: not applicable.
Disclosure of interest: the authors declare that they have no competing
interests.
Supplementary data
Supplementary data associated with this article
can be found, in the online version, at https://
doi.org/10.1016/j.ortho.2020.11.004.
11
 To cite this article: Sharma VK, et al. Variables to predict spontaneous eruption of palatally displaced permanent canine after
interceptive extraction of primary canine: A systematic review and meta-analysis. International Orthodontics (2020), https://doi.
org/10.1016/j.ortho.2020.11.004
V.K. Sharma, N.K. Shukla, T.P. Chaturvedi, S. Singh
Systematic review and meta-analysis
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