Bull. Tokyo dent. Coll., Vol. 40, No. 4, pp.

203⬃208, November, 1999 203

Case Report

THE HORIZONTALLY IMPACTED MAXILLARY CANINE

SITUATED IN A LABIAL POSITION

KIYOSHI MOCHIZUKI, KEIICHIRO TSUJINO, TAKURO YONEZU

and MASASHI YAKUSHIJI

Department of Pediatric Dentistry, Tokyo Dental College,

1-2-2 Masago, Mihama-ku, Chiba 261-8502, Japan

Received 2 July, 1999/Accepted for Publication 1 October, 1999

Abstract
Surgical management of unerupted teeth depends upon a through understanding
of anatomic, physiologic and pathologic factors. Attention has been given to problems of
eruption in the maxillary anterior region. It is a region where a variety of anomalies occur.
Since the maxillary anterior region influences appearance so greatly, early detection of
difficulties and careful planning and treatment can be extremely beneficial to patients.
The purpose of this case report is to present a case of maxillary permanent canine
impaction in a horizontal displacement that developed after loss of the deciduous canine
to chronic apical periodontitis, and incomplete root resorption of the deciduous canine.
Key words: Impacted teeth— Maxillary canine —Labial position—
Fenestration—Traction

INTRODUCTION patients, canine impaction occurs as a result

The maxillary canine is not a very rare
dental anomaly, yet its treatment is usually a
challenge to orthodontic approach7,8,10,13). Any
tooth in the dental arch can be impacted, but
the teeth most frequently involved in a
descending order are the mandibular and
maxillary third molars, the maxillary canines,
the mandibular and maxillary second pre-
molars, and the maxillary central incisors9,11,12).
However, in two percent of the orthodontic
of a deviation from the normal sequence of
dental development1,3,6,15). Canine impaction is
ten to twenty times more common in the
maxilla than in the mandible11). The reported
frequency of palatal versus buccal impaction
varies from rates of 2:1 to as high as 12:15,8,15).
The majority of canines are impacted pala-
tally among Caucasians and buccally among
Asians. Over 50 percent of Asians present a
tapered arch form, resulting in more severe
crowding in the anterior segment11,16,18). Some-

A major part of this study was presented at the 52nd Annual Session of American Academy of Pediatric
Dentistry, 1999 in Toronto.

203
204 K. MoCHIZUKI et al.
Fig. 1 A panoramic radiograph shows the initial ex-
amination, right maxillary permanent canine
was impacted. Case 1
Fig. 3 The photograph of patient taken at aged 11
years and 1 month.
times, the path of eruption is ectopic and may
result in a significant horizontal displacement
of the canine.
It is suggested in the following case reports
that a disturbance associated with the radi-
cular granuloma and incomplete root resorp-
tion of the impacted tooth. In the present
paper, treatment is presented for two patients
with a horizontally impacted permanent
canines in a labial position due to chronic
apical periodontitis or incomplete root re-
sorption of the deciduous predecessor.
CASE REPORTS
Case 1
At the age of eleven years and one month,
fenestration and traction of the right maxil-
lary canine tooth were initiated in a Japanese
Fig. 2 Root resorption of the lateral incisor
was not confirmed.
Fig. 4 After the surgical exposure, at aged 11 years
and 4 months.
boy. A panoramic radiograph taken during
the initial examination is shown in Fig. 1, and
a dental radiograph of the same area is shown
in Fig. 2. Due to chronic apical periodontitis
of the deciduous predecessor, the root apex
of the deciduous canine advanced to chronic
apical granulomatous periodontitis, which
subsequently blocked the eruption path of
the right maxillary permanent canine tooth,
causing the tooth to be impacted horizontally.
Although root resorption of the right maxil-
lary lateral incisor was not observed, the
crown of the canine was in contact with the
root of the lateral incisor, thus causing the
crown of the lateral incisor to tilt distally.
A photograph of the dentition at the initial
examination (age: eleven years and one
 IMPACTED MAXILLARY CANINE TEETH
Fig. 5 The hook was reattached to the labial surface
of the canine, at aged 11 years and 8 months.
Fig. 7 At the age of 13 years and 8 months, six
months after the completion of treatment.
month) is shown in Fig. 3. At the same time,
a palatal arch was set, the right maxillary
deciduous canine tooth was removed, and
bone fenestration was performed from the
labial side using an electric knife and a bone
chisel. After surgical exposure, a hook was
attached to the neck region of the exposed
canine tooth by the direct bonding method,
and traction was initiated using elastic thread
(Fig. 4). The fenestrated area was protected
by a surgical pack. After some time, the hook
was reattached to the labial surface of the
canine tooth, and traction was continued
(Fig. 5). At the age of twelve years and five
months, traction induced by the palatal arch
was completed, and a bracket was attached to
each maxillary tooth, including the affected
canine tooth. In addition, a coaxial wire was
used to induce traction from the labial side
and canine guidance was started (Fig. 6). A
205
Fig. 6 At the age of 12 years and 5 months, a bracket
was attached to all maxillary teeth.
photograph of the dentition, six months after
the completion of treatment (age: thirteen
years and eight months) is shown in Fig. 7.
Case 2
At the age of eleven years and eleven
months, fenestration and traction of the left
maxillary canine were initiated in a Japanese
girl. An panoramic radiograph taken during
the initial examination is shown in Fig. 8, and
a dental radiograph of the same area is shown
in Fig. 9. Incomplete root resorption of the
deciduous predecessor was blocking the erup-
tion path of the left maxillary canine, causing
the tooth to be impacted horizontally. Even
though root resorption of the left maxillary
lateral and central incisors was not observed,
the crown of the canine appeared to be in
contact with the root of the left maxillary cen-
tral incisor. At the same time, a palatal arch
was set and the left maxillary deciduous
canine was removed. Bone fenestration was
performed from the labial side using an elec-
tric knife. After surgical exposure, a bracket
was attached to the canine from the fenes-
trated area of the mucous membrane by the
direct bonding method, and traction was
initiated using elastic thread (Fig. 10). The
fenestrated area was protected using a sur-
gical pack. Six months later, the canine
appeared in the oral cavity with a 90 degree
rotation, by the use of elastic polymer mate-
rial. Therefore, a bracket was attached to the
labial surface of the tooth under traction and
all maxillary teeth, and the bilateral central
206 K. MoCHIZUKI et al.
Fig. 8 A panoramic radiograph showing the initial
examination. Left maxillary permanent ca-
nine was impacted. Case 2
Fig. 10 After the surgical exposure, at aged 12 years
and 1 month.
Fig. 12 90-degree counterclockwise rotation was
completed, at aged 13 years and 3 months.
incisors and the left maxillary lateral incisor
were anchored using ligature wire. In addi-
tion, elastic thread was used to improve rota-
tion (Fig. 11). At the age of thirteen years and
three months, although a 90-degree counter-
clockwise rotation was completed (Fig. 12),
Fig. 9 Root resorption of the lateral incisor and
central incisor were not confirmed.
Fig. 11 At the age of 12 years and 7 months, a bracket
was attached to all maxillary teeth.
traction was continued. Following the im-
provement of rotation, traction from the
labial side and canine guidance were initiated
through the use of a 0.016-inch-diameter
round wire by nickel titanium and elastic
thread. At the age of thirteen years and ten
months, treatment for cross-bite of the right
maxillary lateral incisor was started (Fig. 13).
A photograph of the dentition, one year after
the completion of treatment (age: fifteen
years and two months) is shown in Fig. 14.
DISCUSSION
The definition of impacted tooth and re-
tarded eruption remain a subject of disagree-
 IMPACTED MAXILLARY CANINE TEETH
Fig. 13 At the age of 13 years and 10 months, treat-
ment for cross-bite of lateral incisors was
started.
ment among researchers1,4,9). Since teeth
erupt at different times for each person, the
determination of retarded eruption and im-
paction is difficult in a clinical setting. In the
present paper, retarded eruption is defined as
the absence of eruption in the dentition of
immature permanent teeth long after the
eruption age; and impaction is defined as
occurring when mature permanent teeth do
not erupt or immature permanent teeth do
not appear in the oral cavity due to an
anomaly of or an injury to the eruption path.
The etiology of maxillary canine tooth
impaction remains obscure. Several theories
have been proposed to explain the suscepti-
bility of these teeth to impaction1,10,12,13).
The etiology of maxillary canine impaction
is divided into seven groups as follows:
1) failure of the primary canine root to
resorb 2) prolonged retention of the pri-
mary teeth 3) crowding and shortening
of the arch-length 4) localized pathologic
lesions, such as dentigerous cyst 5) ankylosis,
odontoma, or supernumerary tooth 6) small
or congenitally missing lateral incisors,
and 7) other hereditary patterns2,10,11,14).
In both of the patients examined in the
present study, the maxillary canine teeth trav-
eled within the facial bone while avoiding a
radicular granuloma or incomplete root re-
sorption of the deciduous predecessor, thus
causing the canine to be impacted horizon-
tally. Although in Caucasians, maxillary
canine teeth are often impacted palatally, the
207
Fig. 14 At the age of 15 years and 2 months, one year
after the completion of treatment.
canine teeth were impacted in a labial posi-
tion in the two patients examined in the
present study. Kuftinec et al.12) reported that,
when impacted labially, the canine teeth are
most often found in a vertical position. How-
ever, in the present cases, the canine teeth
were impacted labially in a horizontal posi-
tion. Furthermore, Oliver et al.16) documented
that Asians present a tapered arch form,
resulting in more severe crowding in the ante-
rior segment. The majority of canines are
impacted palatally among Caucasians and
buccally among Asians. Caucasians and
Asians; the highest incidence occurs among
Japanese people. This difference may demon-
strate a racial link in this abnormality. The
cause of canine impaction in Case 1 was
a radicular granuloma, and although the
intercanine tooth width was wide and crowd-
ing did not present a problem, the canine
tooth was impacted horizontally. The other
side, Case 2 was traumatic injury to the
maxillary anterior region at an early stage of
dental development, which has also been sug-
gested as a possible etiologic factor in canine
impaction.
When the angle of a horizontally impacted
canine is severe and when the eruption of the
crown is directed toward the lateral incisor,
root resorption of the lateral incisor must be
suspected. However, root resorption of the
lateral incisor was not confirmed in these two
patients.
The tooth germ of the maxillary canine
208 K. MoCHIZUKI et al.
originates high in the maxillary sinus just
underneath the orbit at 4–5 months of preg-
nancy. Calcification begins 5–6 months after
birth, and the maxillary canine teeth gener-
ally erupt in the oral cavity at around the age
of ten. The eruption path for the maxillary
canine is the longest among all teeth. The
tooth germ of the maxillary canine is located
in the most complicated area of the facial
bones, and the time from the formation of
the tooth germ until the eruption of the tooth
is prolonged for these teeth. Therefore, vari-
ous factors can cause positional abnormali-
ties. In Case 1, chronic apical granulomatous
periodontitis present in the eruption path of
the maxillary canine blocked the progress of
the tooth. In Case 2 examined in the present
study, root resorption of the deciduous prede-
cessor was incomplete, and so the tooth germ
of the maxillary permanent canine remained
high in the maxillary bone for an extended
time, reducing the eruptive force of the tooth.
Consequently, the tooth germ of the canine
moved horizontally toward the root of the
adjacent lateral incisor. Canine teeth that are
subject to severe horizontal impaction in a
labial position are less likely to erupt properly,
even after the cause of impaction is elimi-
nated. Therefore, when the natural eruptive
force of tooth is reduced or anomalies of the
dentition or occlusion are suspected, these
eruption must be actively guided by fenestra-
tion or traction.
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Reprint requests to:
Dr. Kiyoshi Mochizuki
Department of Pediatric Dentistry,
Tokyo Dental College,
1-2-2 Masago, Mihama-ku,
Chiba 261-8502, Japan