To cite this article: Elangovan B, et al.

Effectiveness of various interceptive treatments on palatally displaced canine–a systematic

review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

International Orthodontics 2019; //: ///

Websites:
www.em-consulte.com
www.sciencedirect.com

Systematic review
Effectiveness of various interceptive
treatments on palatally displaced
canine–a systematic review

Bharathi Elangovan, Haritha Pottipalli Sathyanarayana, Sridevi Padmanabhan

Available online: Department of Orthodontics, Sri Ramachandra Institute of Higher Education and
Research, 1 Ramachandra Nagar, Chennai, 600116, India

Correspondence:
Bharathi Elangovan, Department of Orthodontics, Sri Ramachandra Institute of
Higher Education and Research, 1 Ramachandra Nagar, Chennai, 600116, India.
bharathiek2016@gmail.com

Keywords
Palatally impacted canines
maxillary impacted canine
interceptive treatment
Palatally Displaced Canine
Interceptive treatment
Palatal Displaced Canines
Summary
Objective > The aim of this systematic review was to assess whether interceptive treatment carried
out in the mixed dentition period improves the position of Palatally Displaced Canines (PDC).
Materials and Methods > A systematic search was performed on various computerized databases. A
hand search was also performed by reviewing the references within the examined studies and
titles of the papers published over the last 30 years on various orthodontic journals.
Results > This systematic review analysed eight articles, of which five were Randomized Clinical
Trials (RCT) and three were prospective control studies. Qualitative assessment was done for all the
eight studies. The effect of interceptive measures such as extraction of primary canine, Rapid
Maxillary Expansion (RME), cervical pull headgear and Transpalatal Arch (TPA) on successful
eruption of Palatally Displaced Canines was analyzed.
Conclusion > Interceptive treatment improves the position of PDC and reduces the chances of
impaction. Significant changes in success rate depend on diagnosis at early mixed dentition stage.
A combination of interceptive measures which includes extraction of primary canine, cervical pull
headgear, TPA and RME aided in successful eruption. However, Randomized clinical trials with
increased sample size, proper randomization comparing all the interceptive measures along with
assessment of other factors such as patient satisfaction, pain experience and cost factor will yield
more evidence based conclusions.

Mots clés Résumé

Canine incluse palatine
Canine incluse maxillaire Efficacité des divers traitements interceptifs sur les canines palatines ectopiques – revue
Traitement interceptif systématique
Canine ectopiques
Objectif > L'objectif de cette étude systématique était d'évaluer si les traitements interceptifs
palatines
effectués pendant la période de dentition mixte améliorent la position ectopique palatine des
Traitement interceptif
canines (PDC).

tome xx > 000 > xx 2019

1

https://doi.org/10.1016/j.ortho.2019.08.002
© 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.

ORTHO-411
 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

B. Elangovan, H. Pottipalli Sathyanarayana, S. Padmanabhan

Systematic review

canines ectopiques Matériels et méthodes > Une recherche systématique a été effectuée dans diverses bases de
palatines données informatiques. Une recherche manuelle a également été menée en analysant les
références bibliographiques des études retenues ainsi que les titres des articles publiés au cours
des 30 dernières années dans diverses revues orthodontiques.
Résultats > Cette revue systématique a analysé huit articles, parmi lesquels cinq étaient des
essais cliniques randomisés et trois étaient des études cas témoins prospectives. Une évaluation
qualitative a été effectuée pour les huit études. L'effet des mesures d'interception telles que
l'extraction de la canine temporaire, l'expansion du maxillaire, la force extra-orale et l'arc
transpalatin sur le succès de l'éruption des canines ectopiques palatines a été analysé.
Conclusions > Le traitement interceptif améliore la position des canines ectopiques palatines et
réduit les risques d'inclusion. Le taux de succès varie significativement selon la précocité du
diagnostic en dentition mixte. La combinaison de mesures d'interception comprenant l'extraction
de la canine primaire, la force extra-orale, l'arc transpalatin et l'expansion maxillaire (RME) a
contribué au bon pronostic d'éruption de la canine. Cependant, des essais cliniques randomisés
avec un échantillon de plus grande taille, une randomisation appropriée comparant toutes les
mesures d'interception ainsi qu'une évaluation d'autres facteurs tels que la satisfaction du
patient, l'expérience de la douleur et le facteur coût permettront de tirer des conclusions
davantage fondées sur des données probantes.

Introduction The first and foremost interceptive treatment measure consid-

An impaction is a condition characterized when a tooth fails to
erupt into the dental arch within the expected time. Maxillary
canines are the second most commonly impacted teeth follow-
ing the third molars [1]. Maxillary canines erupt at a mean age of
10.5 years in girls and 11.5 years in boys with an individual
variation of 3–4 years [1–7]. Maxillary canines may fail to erupt
due to hard tissue or soft tissue obstruction or an abnormal path
of eruption.
According to studies conducted by Ericson and Kurol, Maxillary
canines are positioned palatal to the dental arch in 85% of the
cases and buccal in only 15% of the cases [2]. Peck et al. first
described the term Palatally Displaced Canine (PDC) as a "devel-
opmental dislocation'' with genetic predisposition. The preva-
lence rate of PDC ranges between 0.8% to 5.2% [1,3]. PDC is a
developmental dislocation of the canine towards the palatal
region due to various factors such as arch length discrepancy,
retained deciduous tooth and trauma during formation of the
tooth [4]. PDC most often leads to impaction of the canine, root
resorption of permanent incisors and in some cases formation of
cysts occurs [5,6]. To overcome these difficulties, early diagnosis
of PDC is necessary and if diagnosed early, it can be managed
with appropriate interceptive measures.
Many studies have focused on the interceptive treatment of PDC.
Various interceptive procedures include extraction of deciduous
canine, transpalatal arch, headgear to distalize the upper buccal
segments and maxillary expansion as a method of gaining space
[7–17]. Most of the studies have evaluated the position of PDC
either with extraction of the primary canine alone or in combi-
nation with the above mentioned interceptive treatment and
concluded that eruption of PDC improves with early intervention.
2
ered in reducing the prevalence of impacted PDC was the
extraction of deciduous canine [18]. Ericson and Kurol suggested
that 78% of PDC changed to normal eruption between 6 and
12 months following the extraction of the primary canine [7].
Power and Short also concluded in their study that extraction of
primary canines favours the normal eruptive path for PDC [8].
Kettle emphasized on combination of an additional interceptive
measure along with the extraction of the primary canine, which
increases the rate of successful eruption of PDC [19]. The objec-
tive of the additional measures with extraction of primary
canine was to prevent the mesialisation of upper permanent
molars into the extraction space and expansion of the maxillary
arch in arch length tooth size discrepancy.
However, a systematic review published in 2012 by Parkin et al.
concluded that there is no reliable evidence of the effects of
extraction of primary canine teeth on the PDC in 10–13 year old
children [20]. In 2010, a systematic review by Naoumova et al.
was conducted to assess whether the interceptive treatment on
mixed dentition prevents impaction of PDC [21]. Authors had
included two studies in which extraction of primary canine
followed by a headgear was used as an interceptive method.
Authors concluded that there is no evidence-based conclusion
on which interceptive procedure is effective in PDC. The reasons
mentioned were few studies, heterogeneity in study design,
and the unequivocal results. Several randomized studies have
been published on interceptive measures of PDC after the
above-mentioned systematic reviews by Parkin et al. and Naou-
mova et al. These studies suggested that interceptive measures
which includes extraction of primary canine, cervical pull head-
gear, Rapid Maxillary Expansion and transpalatal arch helps in

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

Effectiveness of various interceptive treatments on palatally displaced canine–a systematic review

Systematic review
TABLE I
Summary of the search database. TABLE III
Rejected articles after full text assessment.
Keywords Database Number of
articles selected Name of the article Reason for rejection

Palatally impacted canines Medline 167 Bruks A, Lennartsson B (1999) [40] Includes both interceptive
and corrective treatment
Maxillary impacted canine, Google scholar 150
Interceptive treatment
Palatally displaced canine Medline 86
Interceptive treatment and Medline 10
Palatal Displaced Canines

used in each database are given in table I. A hand search was

also performed by reviewing the references within the exam-
ined studies and titles of the papers published over the last
30 years on various orthodontic journals.
TABLE II
Selected articles based on title and abstract.
Eligibility criteria
Selected studies should be a Randomized Controlled Trial (RCT),
Keywords Database Number of articles prospective or retrospective clinical study. These studies should
selected based on have included healthy patients without any systemic diseases.
title and abstract, PDC should have been diagnosed from panoramic radiographs
exclusion of
or lateral cephalogram or cone beam computed tomography
repetitions
(CBCT) and intra oral periapical radiographs with the Clark's tube
Maxillary impacted Google scholar 1 shift technique. Studies should have included at least one
canine, interceptive
interceptive treatment measure on the PDC and the interceptive
treatment
Interceptive Medline 7 measures to be non-surgical.
treatment and palatal
Inclusion criteria
displaced canines
 Randomized Clinical Trial, prospective or retrospective control
study.
 Mixed dentition with unilateral or bilateral PDC.
 Assessment with radiographs and study models.
 Studies should involve at least one interceptive treatment
preventing impaction of canine, thus reducing the orthodontic procedure.
treatment time and most importantly avoids the need for sur-
Exclusion criteria
gical management. Hence there was a need for a systematic
Case reports, case series, preliminary reports, reviews, letter to
review to include all the clinical studies published till August
the editor and comments.
2017 date to assess the effectiveness of the interceptive mea-  Studies with the surgical exposure of PDC as a treatment
sures in the mixed dentition to prevent the impaction of PDC.
option.
The aim of this systematic review was to assess whether inter-  Treatment with fixed appliances with extraction of permanent
ceptive treatment carried out in the mixed dentition period
teeth.
improves the position of PDC.  In vitro studies.

 Studies involving animals as subjects.

Materials and methods
Data abstraction
Two authors did the selection process. The data extracted from
each article was compared and discussed to resolve any dis-
crepancies and to reach a unanimous consensus.
Search method
Articles were selected through a literature survey on computer-
ized databases. The databases were 1) Medline 2) Google
scholar 3) PubMed 4) Cochrane library. The search algorithms
 Studies without control group.
The selected and rejected articles after assessment of the full
text articles are mentioned in tables II and III respectively and
figure 1 describes the search strategy. A summary of the articles
included in this systematic review is mentioned in table IV.
Quality assessment
The selected articles were graded based on the criteria proposed
by Cochrane Collaboration for RCT [22], (table V) and Prospective
case-control studies [23], (table VI). The risk of bias within
3

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

B. Elangovan, H. Pottipalli Sathyanarayana, S. Padmanabhan

Systematic review

TABLE IV
Summary of full text articles included in qualitative synthesis.

S. number Author Sample Treatment measure Control Study design

1. Leonardi et al. (2004) [9] 75 subjects EC: Extraction of primary canine 22 subjects Prospective
EC:23 subjects EHG: Extraction of primary canine mean age 11.6 years control study
mean age 11.7 years followed by cervical pull
EHG: 24 subjects headgear
mean age 11.9 years
2. Baccetti et al. (2008) [10] 50 subjects EC: Extraction of primary canine 14 subjects Prospective
EC: 11 subjects EHG: Extraction of primary canine mean age 11.6 years control study
mean age 11.6 years followed by cervical pull
EHG: 21 subjects headgear.
mean age 12.2 years
3. Baccetti et al. (2009) [13] 60 subjects Banded RME followed by retainer 25 subjects Randomized
RME 35 subjects age 7.6–9.6 years clinical trial
age 7.6–9.6 years
4. Armi et al. (2011) [15] HG group: HG: cervical pull headgear 22 subjects, Randomized
17 subjects, RME/HG: Banded RME followed mean age of 11.6 years clinical trial
mean age 11.9 years by cervical pull headgear
RME/HG group:
21 subjects,
mean age 11.1 years
5. Baccetti et al. (2010) [14] 120 Subjects RME/TPA/EC: 30 subjects Randomized
RME/TPA/EC: Bonded RME followed by TPA and age 9.5–13 years clinical trial
40 subjects Extraction of primary canine
TPA/EC: TPA/EC: TPA in combination with
25 subjects extraction of primary canine.
EC: 25 subjects EC: Extraction of primary canine
age 9.5–13 years
6. Sigler et al. (2011) [16] 70 Subjects RME/TPA/EC: 30 subjects Prospective
RME/TPA/EC: Bonded RME followed by TPA and Mean age: 10.5 years control study
40 subjects Extraction of primary canine
age 9.5–13 years 35 subjects
Banded RME 5 subjects
7. Bazargani et al. (2014) [12] 24 subjects Extraction of deciduous canine. 24 subjects Prospective
mean age 11.6 years randomized
controlled study
8. Naoumova et al. (2015) [17] 67 subjects Extraction of deciduous canine. 22 subjects Randomized
age 10–13 years clinical trial

List of abbreviations: Control group: CG; Treated group: TG; No treatment group–NTG; EC: Extraction Group; EHG: Extraction and headgear group; Dental pantomogram: DPT; Cone
Beam Computed Tomography: CBCT; HG-Headgear; RME: Rapid Maxillary Expansion; TPA: Transpalatal Arch; EC: Extraction of primary canine.

TABLE V
Summary of the quality assessment of randomized control studies.

Quality assessment Study Sequence Allocation Blinding of participants Blinding of Incomplete Selective Other sources Overall
Name generation concealment and personnel outcome outcome data outcome of bias bias
assessors reporting
Baccetti et al. (2009) Unclear Unclear Low Low Low Low Unclear Unclear
Baccetti et al. (2010) Unclear Unclear Low Low Low Low Unclear Unclear
Armi et al. Unclear Unclear Low Low Low Low Unclear Unclear
(2011)
Bazargani Low Low Low Low Low Low Unclear Low
et al. (2014)
Naoumova Low Low Low Low Low Low Unclear Low
et al. (2015)
4

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

Effectiveness of various interceptive treatments on palatally displaced canine–a systematic review

Systematic review
TABLE VI
Summary of the quality assessment of prospective case control studies.

Quality Exposed and Assessment Absence Matching of Assessment of the Outcome Follow up Co-intervention Quality
assessment non-exposed of exposure of outcome variables presence or absence assessment of cohort of study
Study name cohorts from interest during of prognostic factors
same population sampling
Leonardi et al. Definitely Probably Probably Definitely Definitely Low
(2004) Yes Definitely Probably Probably Yes Yes Yes Yes risk
yes Yes Yes bias
Baccetti et al. Definitely Probably Probably Definitely Definitely Low
(2008) Yes Definitely Probably Probably Yes Yes Yes Yes risk
yes Yes Yes bias
Sigler et al. Definitely Probably Probably Definitely Definitely Low
(2011) yes Definitely Probably Probably yes yes Yes yes risk
yes yes yes bias

Results
The results were analysed based on the effect of interceptive
measures on successful eruption of Palatally Displaced Canines
(table VII).

Extraction of primary canine

Naoumova et al., 2015–Extraction of deciduous canine showed
significant difference between control and extracted group [17].
Bazargani et al., 2014–Extraction of primary canine showed
increase in the prevalence rate of successful eruption of PDC
[12].
Leonardi et al., 2004, Baccetti et al., 2008–Significant increase in
successful eruption of PDC with extraction of primary canines
when compared with untreated groups, cervical pull headgear
along with extraction of primary canine had a higher prevalence
rate in the successful eruption of PDC than the other two groups
[9,10].

Rapid Maxillary Expander (RME)

Baccetti et al., 2009–Significant increase was observed with RME
in early mixed dentition between treated and untreated group
[13].
Baccetti et al., 2010, Sigler et al., 2011–RME in addition to
transpalatal arch (TPA) and extraction of primary canine showed
greater significance when compared with extraction of primary
canine alone and minimal significant difference with the group
which had been treated with TPA and extraction of primary
Figure 1
canine [14,16].
Flow chart describing the search strategy.

studies was assessed independently by the two authors and
across studies by an independent reviewer. Any disagreement
was resolved by discussion with the reviewer.
Headgear
Armi et al., 2011–Significant increase in the success rate of PDC
was observed with RME and headgear when compared to use of
headgear alone as an interceptive measure [15].
5

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

B. Elangovan, H. Pottipalli Sathyanarayana, S. Padmanabhan

Systematic review

TABLE VII
Summarized results of the included articles.

Article Methods Investigating method Observation time and Success rate of Outcome/authors Side effects/cost/
follow up time canine erupted conclusion patient discomfort

Leonardi et al. EC versus EC Lateral cephalogram Observation time: Assessed after Significant Not assessed
(2004) followed by and DPT 18 months 48 months difference
cervical pull Follow-up period EC: 50% between EC and
headgear versus 30 months after EHG: 80% EHG group and no
non extraction. observation period significant
difference on time
required for canine
eruption
Baccetti et al. EC versus EC Lateral cephalogram Observation time: Assessed after Extractions resulted Not assessed
(2008) followed by and DPT 18 months 48 months in more than twice
cervical pull EC: 65.2% as successful
headgear versus EHG: 87.5% eruption of PDC
non extraction. CG: 36.5% compared with CG.
EHG was almost
three times more
effective than CG
Baccetti et al. RME for expansion PA Observation period: Assessed after Use of RME in Not assessed
(2009) and as retainer for Cephalogram TG: 4.4 years observation period early mixed
6 months followed Panaromic NTG: 4.11years TG: 65.7% dentition is
by retention plate radiograph and Dental NTG: 13.6% effective when
for 1 year at night. casts compared with
control group.
Armi et al. HG for a year (12- Panaromic radiograph, Observation time: Assessed after No significant Not assessed
(2011) 14 hrs a lateral cephalogram 18 months for every 18 months difference
day). RME/HG: and study cast group HG: 82.3% between the HG
Banded RME for RME/HG: 85.7% and RME/HG
expansion and as groups.
retainer for Significant
6 months followed difference was
by HG for a year observed when
compared with
control group.
Baccetti et al. RME/TPA/EC Panaromic Observation period RME/TPA/EC: Statistical Not assessed
(2010) radiograph RME/TPA/EC: 80% difference
and lateral 3 years 6 m  16 m TPA/EC:79.2% between all the
cephalogram TPA/EC: 2years EC: 65.2% groups with
9m  13 m CG: 27.6% exception between
EC: 2years 2m  10 m RME/TPA/EC and
CG:3years 1m  14 m TPA/EC
Sigler et al. RME/TPA/EC Panoromic radiograph, Observation TG: 79.5% Significant Not assessed
(2011) lateral cephalogram period: CG: 27.6% difference
and dental casts. TG: 3 years 7 m between treated
CG:3 years 1 m and control group
Bazargani EC Panaromic radiograph, Observation time: Assessed after Extraction as an Not assessed
et al. (2014) Intraoral radiograph, 18 months(6 month 18 months effective measure
study casts interval) Extraction site: in younger
67% patients with early
Control Site: 42% diagnosis.
Palatal arch is
recommended to
maintain perimeter
of the upper arch.
No midline shift
6

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002
Effectiveness of various interceptive treatments on palatally displaced canine–a systematic review
TABLE VII (Continued).
Article Methods Investigating method
Naoumova EC CBCT
et al. (2015)
List of abbreviations:Control group: CG; Treated group: TG; No treatment group; NTG, EC: Extraction Group, EHG: Extraction and headgear group; Dental pantomogram: DPT; Cone Beam
Computed Tomography: CBCT; HG-Headgear; RME: Rapid Maxillary Expansion; TPA: Transpalatal Arch; EC: Extraction of primary canine.
Discussion
The aim of this systematic review was to assess whether inter-
ceptive treatment reduces the incidence of impaction of PDC and
improves the position. Since RCTs are considered as the gold
standard among all research designs in the evidence pyramid,
our systematic review focused on studies which are clinical trials
and prospective controlled studies. Case reports and case series
were not taken into consideration due to the inadequacies in
their study design to address the objective of this systematic
review. A computerized search was made on literature and a
total of eight articles were selected which fulfilled our inclusion
criteria (figure 1). Of the eight articles, five studies were Ran-
domized clinical trials and three were prospective control stud-
ies (table II). A significant number of selected studies appeared
in the PubMed database. One article was rejected since the
retrospective study compared the interceptive and corrective
treatment of Palatally Displaced Canines (table III). Risk of bias
for randomized control studies was assessed with the Cochrane
risk of bias assessment for RCT (2013). Prospective control
studies were assessed with Cochrane Collaboration for prospec-
tive case-control studies. On performing quality assessment of
selected eight studies, two RCT and three prospective studies
showed a low risk of bias and remaining three RCT showed an
unclear risk of bias.
The results were analysed based on the effect of interceptive
measures on successful eruption of PDC.
Various interceptive procedures are extraction of deciduous
canine, headgear and Rapid Maxillary Expansion. The extraction
of the deciduous canine as an interceptive measure to improve
the position of PDC has been included in many RCT's. The
prospective study by Ericson and Kurol in 1988 analysed the
effects of extraction of the deciduous canine on PDC in terms of
rate and time of "spontaneous'' eruption. In 36 out of 46 canines
(78%), palatal eruption changed to normal, with duration of
tome xx > 000 > xx 2019
Systematic review
Observation time and Success rate of Outcome/authors Side effects/cost/
follow up time canine erupted conclusion patient discomfort
Observation time: Extraction group: Significant increase Root
24 months 69% in the successful resorption
Control group: eruption of PDC in was assessed.
39% extracted group No significant
difference in
root resorption of
adjacent teeth
between the
groups
eruption ranging from six to twelve months [7]. In a longitudinal
two-year investigation in 1993, Power and Short described the
achievement of a normal eruptive position of PDC in 62% of the
cases after the extraction of the deciduous canines [8]. Leonardi
et al. in 2004 suggested that the removal of the deciduous
canine alone as an interceptive measure was ineffective to
increase the eruption rate of palatal displaced maxillary canines
after evaluating the position of canine at T1 and T2 (after
18 months of observation period) on panoramic radiographs
and concluded that addition of cervical pull headgear induces
successful eruption of PDC in 80% of cases [9].
Baccetti et al. in 2008 concluded that cervical-pull headgear with
extraction of the primary canine as a treatment measure which
increased the rate of successful eruption of PDC to 87.5%. A
superimposition of lateral cephalograms of control group and
extraction of primary canine group at T1 and T2 showed that
mesial movement of upper first molars of about 2.5 mm was
found. Mesialisation of upper first molars was prevented in the
use of headgear group and considered to be an effective treat-
ment measure which increases the rate of successful eruption of
PDC [10]. A study by Olive in 2002 concluded that 75% of canine
erupted successfully after a creating a space by fixed appliance
following extraction of primary canine [11]. Bazargani et al. in
2014 conducted an RCT on the effectiveness of extraction of the
deciduous canine on PDC in which the patients served as both
cases and matched controls and found that the effect was
significantly more pronounced in the younger age group of
10–11 years than in the older patients in the age group of
12-14 years [12]. A systematic review by Almasoud conducted
a systematic review by including four RCT on the management
of PDC and concluded that extraction of primary canine as an
interceptive measure facilitated the eruption of PDC in 50% to
69% of the cases [24]. Baccetti et al. in 2009 analysed the
effects of RME as an early interceptive treatment and found that
7
 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002

B. Elangovan, H. Pottipalli Sathyanarayana, S. Padmanabhan

Systematic review

maxillary expansion was effective as an interceptive procedure
in 65.7% of the patients to prevent final impaction of maxillary
canines with palatal displacement in the early mixed dentition
which was five times greater than untreated controls [13]. The
position of the canine was analysed by PA cephalogram Sam-
bataro et al. method [25]. An indication for RME was based on
the palatal displacement of the canines associated with a Class II
or Class III tendency, or mild tooth-size/arch-size discrepancy
associated with maxillary dentoalveolar constriction with res-
pect to the mandibular arches [26–29]. Aguilo et al. used a self-
organizing maps (SOM) for analysing the problem with the
multiple variables to analyse dental characteristics of patients
who will require surgical exposure and orthodontic alignment in
addition to interceptive treatment. The study involved the pro-
cess of debugging the variables and selecting the appropriate
number of cells to adequately visualize the problem. The
authors analysed the patterns of each of these groups and found
that the initial inclination of the canine and sectors were the
important prognostic factors [30]. Baccetti et al. in 2010 investi-
gated the effectiveness of TPA and extraction of the deciduous
canine, as an interceptive treatment modality for PDC in late
mixed dentition subjects. RME followed by a TPA in conjunction
with extraction of the deciduous canines in late mixed dentition
patients was significantly more effective (80%) than extraction
of the deciduous canines only (65.2 per cent). The use of TPA in
conjunction with the extraction of deciduous canine in late
mixed dentition showed significant results [14]. The success
rate of PDC was high for canine with open apex, lesser alpha
angles and diagnosis at prepubertal CVM stages [31–33]. Sigler
et al., 2011 concluded that RME followed by TPA and extraction
of deciduous canine is effective in late mixed dentition and
confirmed that several dental anomalies are significantly
associated with PDCs and are valuable as early risk indicators
for PDC [16]. Indicators are small lateral incisors, infra occlusion
of deciduous molars and distally displaced erupting mandibular
second premolars [34–39]. Naoumova et al. in 2015 conducted a
RCT on the effectiveness of extraction of deciduous canine on
PDC and root resorption on adjacent teeth. CBCT was used in this
study to assess the position of PDC and was taken twice at six-
month intervals. Surgical exposure and orthodontic treatment
was considered in patients when the canine showed
impairment or no change in its position after 12 months. Sixty
nine percent of permanent canines erupted successfully with a
mean eruption time of 15.6 months and no significant differ-
ences in root resorption of adjacent teeth was present between
the extracted and control group [17].
Conclusion
From the studies included in this systematic review, interceptive
treatment improves the position of Palatally Displaced Canines
and reduces the chances of impaction. Significant changes in
success rate depend on diagnosis at early mixed dentition stage.
Combination of interceptive measures which includes cervical
pull headgear, TPA and RME helps in successful eruption. How-
ever, randomized clinical trials with increased sample size,
proper randomization comparing all the interceptive measures
along with assessment of other factors such as patient satisfac-
tion, pain experience and cost factor will yield more evidence
based conclusions.
Disclosure of interest: the authors declare that they have no competing
interest.

References
[1] Peck S, Peck L, Kataja M. Site-specificity of [7] Ericson S, Kurol J. Early treatment of palatally [11] Olive RJ. Orthodontic treatment of palatally
tooth agenesis in subjects with maxillary erupting maxillary canines by extraction of impacted maxillary canines. Aust Orthod J
canine malpositions. Angle Orthod the primary canines. Eur J Orthod 2002;18:64–70.
1996;66:473–6. 1988;10:283–95. [12] Bazargani F, Magnuson A, Lennartsson B.
[2] Peck S, Peck L, Kataja M. The palatally [8] Power SM, Short MB. An investigation Effect of interceptive extraction of deciduous
displaced canine as a dental anomaly of into the response of palatally displaced canine on palatally displaced maxillary
genetic origin. Angle Orthod 1994;64:250–6. canines to the removal of deciduous canine: a prospective randomized controlled
[3] Bishara SE. Clinical management of impacted canines and an assessment of factors con- study. Angle Orthod 2013;84:3–10.
maxillary canines. Semin Orthod 1998;4:87– tributing to favourable eruption. Br J Orthod [13] Baccetti T, Mucedero M, Leonardi M, Cozza
98. 1993;20:215–23. P. Interceptive treatment of palatal impac-
[4] Thilander B, Jakobsson SO. Local factors in [9] Leonardi M, Armi P, Franchi L, Baccetti T. Two tion of maxillary canines with rapid maxil-
impaction of maxillary canines. Acta Odontol interceptive approaches to palatally displaced lary expansion: a randomized clinical trial.
Scand 1968;26:145–68. canines: a prospective longitudinal study. Am J Orthod Dentofacial Orthop
[5] Bishara SE, Ortho D. Impacted maxillary Angle Orthod 2004;74:581–6. 2009;136:657–61.
canines: a review. Am J Orthod Dentofacial [10] Baccetti T, Leonardi M, Armi P. A randomized [14] Baccetti T, Sigler LM, McNamara Jr JA. An RCT
Orthop 1992;101:159–71. clinical study of two interceptive approaches on treatment of palatally displaced canines
[6] Mcsherry PF. The ectopic maxillary canine: a to palatally displaced canines. Eur J Orthod with RME and/or a transpalatal arch. Eur J
review. Br J Orthod 1998;25:209–16. 2008;30:381–5. Orthod 2010;33:601–7.
8

tome xx > 000 > xx 2019

 To cite this article: Elangovan B, et al. Effectiveness of various interceptive treatments on palatally displaced canine–a systematic
review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.08.002
Effectiveness of various interceptive treatments on palatally displaced canine–a systematic review
[15] Armi P, Cozza P, Baccetti T. Effect of RME and
headgear treatment on the eruption of pala-
tally displaced canines: a randomized clinical
study. Angle Orthod 2011;81:370–4.
[16] Sigler LM, Baccetti T, McNamara JA. Effect of
rapid maxillary expansion and transpalatal
arch treatment associated with deciduous
canine extraction on the eruption of palatally
displaced canines: a 2-center prospective
study. Am J Orthod Dentofacial Orthop
2011;13:e235–44.
[17] Naoumova J, Kurol J, Kjellberg H. 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? Eur J Orthod 2015;37:209–18.
[18] Jacobs SG. Reducing the incidence of uner-
upted palatally displaced canines by extrac-
tion of deciduous canines. The history and
application of this procedure with some case
reports. Aust Dent J 1998;43:20–7.
[19] Kettle MA. Treatment of the unerupted max-
illary canine. Trans Br Soc Orthod 1957;32:74–
84.
[20] Parkin N, Benson PE, Shah A, Thind B,
Marshman Z, Glenroy G, Dyer F, Benson
PE. Extraction of primary (baby) teeth for
unerupted palatally displaced permanent
canine teeth in children. Cochrane Database
Syst Rev 2012;12:CD004621.
[21] Naoumova J, Kurol J, Kjellberg H. A systema-
tic review of the interceptive treatment of
palatally displaced maxillary canines. Eur J
Orthod 2010;33:143–9.
[22] Ryan R, Hill S, Prictor M, McKenzie J, Cochrane
Consumers and Communication Group. Study
quality guide. cccrg.cochrane.org/author-
resources May 2013.(accessed 2016).
tome xx > 000 > xx 2019
[23] National Institutes of Health, Department of
Health Human Services U.S. Quality Assess-
ment of Case-Control Studies. National Insti-
tutes of Health; 2014 [Retrieved from
https://www.nhlbi.nih.gov/health./study-
quality-assessment-tools].
[24] Almasoud NN. Extraction of primary canines
for interceptive orthodontic treatment of
palatally displaced permanent canines: A sys-
tematic review. Angle Orthod 2017;87:878–
85.
[25] Sambataro S, Baccetti T, Franchi L, Antonini
F. Early predictive variables for upper canine
impaction as derived from posteroanterior
cephalograms. Angle Orthod 2005;75:28–34.
[26] Langberg BJ, Peck S. Adequacy of maxillary
dental arch width in patients with palatally
displaced canines. Am J Orthod Dentofacial
Orthop 2000;118:220–3.
[27] Cameron CG, Franchi L, Baccetti T, McNa-
mara JA. Long-term effects of rapid maxillary
expansion: a posteroanterior cephalometric
evaluation. Am J Orthod Dentofacial Orthop
2002;121:129–35.
[28] Al-Nimri K, Gharaibeh T. Space conditions
and dental and occlusal features in patients
with palatally impacted maxillary canines: an
aetiological study. Eur J Orthod 2005;27:461–5.
[29] Saiar M, Rebellato J, Sheats RD. Palatal
displacement of canines and maxillary skele-
tal width. Am J orthod Dentofacial orthop
2006;129:511–9.
[30] Gandia-Aguilo V, Cibrian R, Soria E, Serrano
AJ, Aguilo L, Paredes V, Gandia JL. Use of
self–organizing maps for analyzing the beha-
vior of canines displaced towards midline
under interceptive treatment. Med Oral Patol
Oral Cir Bucal 2017;22:e233–41.
Systematic review
[31] Baccetti T, Franchi L, De Lisa S, Giuntini V.
Eruption of the maxillary canines in relation to
skeletal maturity. Am J Orthod Dentofacial
Orthop 2008;133:748–51.
[32] Baccetti T, Franchi L, McNamara JA. The
cervical vertebral maturation (CVM) method
for the assessment of optimal treatment tim-
ing in dentofacial orthopedics. Semin Orthod
2005;11:119–29.
[33] Nolla CM. The development of the perma-
nent teeth. J Dent Child 1960;27:254–66.
[34] Shapira Y, Kuftinec MM. Maxillary tooth
transpositions: characteristic features and
accompanying dental anomalies. Am J Orthod
Dentofacial Orthop 2001;119:127–34.
[35] Björk A, Skieller V. Normal and abnormal
growth of the mandible. A synthesis of long-
itudinal cephalometric implant studies over a
period of 25 years. Eur J Orthod 1983;5:1–46.
[36] Baccetti T. A controlled study of associated dental
anomalies. Angle Orthod 1998;68:267–74.
[37] Baccetti T, Leonardi M, Giuntini V. Distally
displaced premolars: a dental anomaly asso-
ciated with palatally displaced canines. Am J
Orthod Dentofacial Orthop 2010;138:318–22.
[38] Wasserstein A, Brezniak N, Shalish M, Heller
M, Rakocz M. Angular changes and their
rates in concurrence to developmental stages
of the mandibular second premolar. Angle
Orthod 2004;74:332–6.
[39] Shalish M, Chaushu S, Wasserstein A. Mal-
position of unerupted mandibular second pre-
molar in children with palatally displaced
canines. Angle Orthod 2009;79:796–9.
[40] Bruks A, Lennartsson B. The palatally displaced
maxillary canine. A retrospective comparison
between an interceptive and a corrective treat-
ment group. Swed Dent J 1999;23:149–61.