STEVEN J. LINDAUER, D.M.D., M.D.S.; LORETTA K.
RUBENSTEIN,
ABSTRACT
T h is s tu d y e v a lu a te s th e
e f fe c t iv e n e s s o f th e
p a n o r a m ic r a d io g r a p h in
p r e d ic tin g c a n in e p a la ta l
im p a c tio n .
D.D.S.; WILLIAM M. HANG, D.D.S., M.S.D.; W. C L A R K ANDERSEN,
D.D.S.; ROBERT J. ISAACSON, D.D.S., M.S.D., PH.D.
Q p anine palatal im paction occurs once in about every 100 people.1,2
Often these impactions go undiagnosed well beyond the tim e of
norm al canine eruption for two reasons:
■* P rim ary canines are shaped sim ilarly to perm anent canines, and
it is difficult to distinguish clinically betw een retained prim ary
canine crowns and perm anent canine crowns;
■" M axillary canines tend to erupt late r in the usual eruption
sequence of m axillary teeth.
In addition, when crowding occurs eruption can be delayed even
w hen th e canine is not im pacted. The re su lt is th a t canine palatal
im pactions are not usually prevented. O ften they’re treated only
after protracted observation, in hopes th a t eruption will occur
w ithout intervention.
T reating im pacted palatal canines usually involves surgery plus
orthodontic therapy to place the tooth in its correct position.34
These procedures offer a high success ra te in adolescents b u t
involve substantial tim e and cost. They also increase the risk of
gingival recession, bone loss and detached gingiva around the
treated canine.4
A m ethod for early detection and prevention of canine palatal
impactions would reduce the need for such complicated treatm en ts
and potentially improve the canine’s long-term prognosis.
One suggested preventive procedure for canine palatal im paction
is early extraction of the corresponding prim ary canine,56 on the
basis th a t failure of prim ary canine root resorption offers an
obstacle to norm al eruption.7
Ericson and Kurol felt th a t palatal m axillary perm anent canine
im pactions could be prevented by early extraction of the
corresponding m axillary prim ary canines.8 They studied the effect
of extracting 46 such prim ary canines in children aged 10 to 13
years.8
Ericson and Kurol didn’t define palatal placem ent but determ ined
it by a series of radiographs—panoram ic, occlusal, lateral and
periapical films. They reported th a t 78 percent of the ectopic
canines had a norm al eruption p ath after th is procedure. Since no
u n treated group was examined, we don’t know if any of these
JADA, Vol. 123, March 1992 91
 prim ary
canines
improves the
chances for
eruption of
perm anent
canines
otherwise
destined to
become
impacted, this
would be a
simple
preventive
approach and
reduce the
need for
Figure 1. Modification of Ericson and Kurol’s“
definition of sectors used in this study: sector I is
complicated
located distal to a tangent to the distal crown and treatm en t
root of the lateral incisor; sector II includes the area procedures.5,6
from the tangent on the distal surface to a midline
bisector of the lateral incisor tooth; sector III To find a
includes the area from the midline bisector to a way to predict
tangent to the mesial surface of the lateral incisor
crown and root; sector IV includes all areas mesial
canine
to sector III. impaction, we
studied the
perm anent canines would have location of the unerupted
erupted norm ally w ithout the perm anent canine cusp tip
prim ary canine extractions. relative to the erupted lateral
It is difficult to evaluate the incisor root as it appeared on
efficacy of simple interceptive m ixed-dentition panoram ic
procedures designed to prevent radiographs. The locations
canine p alatal impactions served as an indicator to predict
w ithout a reliable way to perm anent canine palatal
predict which canines will impaction.
become im pacted. If extracting The panoram ic radiograph
Figure 2. Radiographs show a typical canine palatal impaction subject and a control subject. Left, the left
canine’s cusp tip is located in sector III, and later became palatally impacted. Right, the right canine cusp
tip is located in sector I, and later erupted normally.
92 JADA, Vol. 123, March 1992
clearly contains considerable
distortion th a t lim its its value
in determ ining the faciolingual
position of unerupted m axillary
canines. Hang, however, reports
empirical evidence th a t the
spatial relationship between the
unerupted m axillary canine and
the erupted perm anent lateral
incisor root on the panoram ic
radiograph can predict canine
palatal impaction.9
In any instance, the dentist
m ust obtain additional
diagnostic information,
including periapical
radiographs, to confirm the
location of the unerupted tooth
and to evaluate potential
damage to adjacent teeth .10 By
establishing a m ethod for
predicting canine palatal
impaction, we can develop
appropriate preventive
m easures, test and use them .
M ETHO DS AND
M A T E R IA L S
We compared panoram ic
radiographs tak en a t an early
stage of dental development
between two groups of patients.
One group consisted of 28
p atients—15 girls and 13
boys—all w ith either unilateral

NUMBER OF CANINE CUSP TIPS LOCATED IN THE VARIOUS SECTORS IN THE CANINE
IMPACTED GROUP AND THE NON-IMPACTED CONTROL GROUP IN THIS STUDY *
IMPACTIONS
B ila te r a l
26 c a n in es
U n ila te r a l
15 c a n in es
TOTAL IMPACTIONS
41 c a n in e s
NON-IMPACTIONS
A g e-m a tch ed
controls
56 c a n in es
U n ila te r a l
15 c a n in es
TOTAL NON-IMPACTIONS
71 c a n in es
*See Figure 1 for definition of sector boundaries.
or bilateral palatally im pacted
canines and currently in the
perm anent dentition. This
im paction group had 41 canine
p alatal impactions: 26 were
bilateral; eight, right unilateral;
and seven, left unilateral.
We defined a canine as
im pacted if it was unerupted
after complete root
development, or if the
contralateral tooth was erupted
for a t least six m onths w ith
complete root formation.
All im pacted canines required
surgery, and we confirmed
visually the radiographic
diagnoses of palatal canine
positions. No patients in the
im paction group had any
extraction or orthodontic
tre a tm e n t before the diagnosis
of im pacted teeth. The m ean
I II III IV
6 lO
3 prim ary second m olars were
9 15 lO
55
13
68 3 relative to th e late ra l incisor
age of the patients a t the tim e
of the earlier panoram ic
radiograph was 12 years, 1
m onth ± 1 1 m onths, in th e late
m ixed dentition.
The second group of 28
chronologically and dentally
age-m atched control patients
was 11 girls and 17 boys whose
56 canines had erupted
normally. None of the patients
had extractions or orthodontic
tre a tm e n t before the eruption of
the perm anent canines.
Average age of the control
group patients at the tim e of
th eir earlier m ixed-dentition
panoram ic radiographs was 11
years, 8 m onths ± 19 m onths.
We evaluated th e panoram ic
radiographs taken during the
late m ixed-dentition period to
determ ine the spatial
relationship betw een the
unerupted perm anent canine
cusp tip and the lateral incisor
root for both groups. O ur
definition of the mixed-
dentition stage was a period in
which lateral incisors were
erupted completely and
m axillary prim ary canines and
retained.
We compared the
radiographic relationships of
the unerupted perm anent
canine cusp tip and the lateral
incisor root betw een the two
groups.
T hree exam iners—unaw are of
the subject groupings—
independently evaluated
random m ixed-dentition
radiographs from the im paction
and control groups. The
exam iners located the
unerupted canine cusp tip
root in one of four sectors using
a modified method of Ericson
and Kurol’s8:
■* Sector I was the area distal
to a line tan g en t to th e distal
heights of contour of th e lateral
incisor crown and root;
™ Sector II was m esial to sector
I, b ut distal to a line bisecting
the m esiodistal dim ension of
the lateral incisor along the
long axis of the tooth;
*■>Sector III was m esial to
sector II, but distal to a line
tan g en t to the m esial heights of
contour of the lateral incisor
crown and root;
«*• Sector IV included all areas
m esial to sector III.
Right and left canines were
scored separately for each
patient. We tested the
differences in the location of the
canine cusp tips betw een the
impaction and control groups
using a X2analysis. Differences
in canine cusp tip locations
JADA, Vol. 123, March 1992 95
betw een the significantly different for the detect incipient carious lesions
im pacted and impaction group compared w ith or early periodontal bone loss, it
non-im pacted the non-impaction control group can provide worthwhile
canine in the (P < 0.001). inform ation regarding the
u nilateral The 15 patients who had presence and general location of
im paction u nilateral canine palatal unerupted teeth. Panoram ic
p atien ts were Dr. Lindauer is
im pactions had normally images are easy to obtain, and
assistant professor,
also tested. Department of
erupted contralateral canines. radiation levels are
It was possible, therefore, to use
Orthodontics, School substantially reduced when
of Dentistry, Medical
RESULTS these patients as th eir own
College of Virginia,
intensifying screens are used in
Virginia controls and to compare their the panoram ic cassettes.
In te r­ Commonwealth
canine cusp tip locations In the mixed-dentition stage,
University,
exam iner Richmond, Va.
relative to the lateral incisor on th ere’s a significant difference
reliability was the mixed-dentition panoram ic
23298-0566. Address in the panoram ic image of the
reprint requests to
93 percent. In Dr. Lindauer.
radiographs between im pacted canine cusp tip relative to the
those seven and non-impacted sides. lateral incisor root between
instances w here one exam iner The results again showed a canines destined to become
differed from the other two, the significant difference between palatally impacted and those
discrepancy was never by more the im pacted and non-impacted th a t will not.
th a n one sector. The exam iners sides (P < 0.005). On the canine Of the palatally impacted
located in the impaction group impaction side, the evaluators canines, 32/41 (78 percent) had
17 of the 41 canine cusp tips in found seven of the 15 canine cusp tips located in sectors II,
sectors III or IV, 15 in sector II cusp tips located in sectors III III or IV of the mixed-dentition
and only nine in sector I. and IV, five in sector II and panoram ic radiographs; only
In the age-m atched control three in sector I. On the non­ nine appeared in sector I. Since
group, the exam iners saw 55 of impaction side, they found 13 of sector I included all areas distal
the 56 canine cusp tips in sector the 15 canine cusp tips in sector to the lateral incisor root, most
I w ith a single exception in I, two in sector II and none in canines destined to become
sector II. They found none of sectors III or IV. palatally impacted had cusp
the control teeth m esial to the tips overlapping or m esial to
line bisecting the lateral incisor D IS C U S S IO N the lateral incisor root. The
m esiodistally (sectors III and sensitivity of this criterion for
IV). The location of the mixed- Although the panoramic predicting canine im paction is
dentition canine cusp tip was radiograph is inadequate to 0.78; 78 percent of all canines
destined to
become
palatal
impactions
were
identified.
In
addition, the
exam iners
located 68 of
71(96
percent) of
the non-
impacted
canine cusp
tips (55/56
age-matched
Figure 3. A control patient’s radiograph with both canine cusp tips in sector I. The canines controls and
later erupted normally. 13/15 non-

96 JADA, Vol. 123, March 1992

impacted canines in the
unilateral impaction group) in
sector I. Only three non-
impacted canine cusp tips
appeared in sector II and none
in sectors III or IV. Therefore,
applying the same test, the
specificity is 0.96—or 96
percent of all permanent
canines will erupt when their
cusp tips do not overlap or lie
mesial to the lateral incisor root
(sector I) on the mixed-dentition
panoramic radiograph.
With a sensitivity of 0.78 and
a specificity of 0.96, this test
helps predict the canines likely
to become impacted.
The average age of the
patients in the impaction group
was 12 years, 1 month at the
time of their mixed-dentition
panoramic radiographs. We
chronologically and dentally
age-matched the control
subjects to the impaction
patients.
To know if the permanent
canine cusp tip position is
equally predictive at an even
earlier chronological age, we
identified a third group of 18
patients identical in all respects
to the age-matched control
group. Each patient in this
third group possessed a dental
record containing a panoramic
radiograph taken at an earlier
chronological age. The average
age of this group at the time of
their panoramic radiographs
was 9 years and 6 months ± 10
months.
As with the older control
group, canine cusp tips
appeared in sectors III or IV,
and 33 (92 percent) of the 36
canine cusp tips were located in
sector I—distal to the lateral
incisor root—not significantly
different between the younger
and older non-impaction
patients (P > 0.05).
The additional younger
chronological age group showed
only the position of non-
impacted canine cusp tips at an
earlier age. It did not address
the position of the tips of
canines destined to become
impacted, as they would appear
at an earlier chronological age.
To address this, it’s necessary
to establish the canine cusp-tip
lateral incisor root spatial
relationships on earlier
panoramic radiographs for
canines that have become
impacted. This step establishes
the earliest possible point in
developing a positive diagnosis
of canine palatal impaction—it
requires identifying a series of
patients with palatally
impacted canines for whom
panoramic radiographs were
taken at an earlier age than
those in this study.
CONCLUSION
When a routine panoramic
survey of a mixed-dentition
patient showed the canine cusp
tip mesial to the long axis of the
erupted lateral incisor root,
canine palatal impaction
occurred. When the canine cusp
tip overlaid the distal half of the
lateral incisor root, a canine
palatal impaction was usually
present.
However, 22 percent of the
canines destined to be palatally
impacted had their cusp tip
distal to a line tangent to the
distal surface of the lateral
incisor. The relationship
between the unerupted canine
cusp tip and the lateral incisor,
as it appeared on the mixed-
dentition panoramic radiograph
identified 78 percent of the
canines destined to become
impacted, but 22 percent
remained undetected. We still
need a method for early
detection of all palatally
impacted canines. ■
The informed consent of all human subjects who
participated in the experimental investigation
reported or described in this manuscript was
obtained after the nature of the procedure and
possible discomforts and risks had been explained
fully.
The authors thank the members of the Medical
College of Virginia Orthodontic Education and
Research Foundation for their cooperation in sharing
their records for inclusion in this study.
Dr. Rubinstein is associate professor, Department
of Orthodontics, School of Dentistry, Medical College
of Virginia, Virginia Commonwealth University. Dr.
Hang is in private practice in Rutland, Vt. Dr.
Andersen is a former postdoctoral student,
Department of Orthodontics, Medical College of
Virginia, Virginia Commonwealth University and in
private practice in Brigham City, Utah. Dr. Isaacson
is professor and chairman, Department of
Orthodontics, Medical College of Virginia, Virginia
Commonwealth University.
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