ORIGINAL ARTICLE

Incisor root resorption associated with

palatally displaced maxillary canines:
Analysis and prediction using
discriminant function analysis
Asma A. Alemam,a Elham S. Abu Alhaija,a Khalid Mortaja,b and Akram AlTawachib
Irbid, Jordan

Introduction: Incisor root resorption associated with palatally displaced canine (PDC-IRR) is an important phe-
nomenon that might alter the orthodontic treatment plan. The aims of this study were to investigate the preva-
lence and characteristics of PDC-IRRs, to compare PDC-IRR and PDC-No-IRR groups, to identify predictors
for PDC-IRR, and to produce a valid PDC-IRR prediction model using discriminant function analysis.
Methods: Cone-beam computed tomography images for 107 palatally displaced canines (PDCs) and 51 fully
erupted nondisplaced canines (NDC) were analyzed for the presence of incisor root resorption (IRR). The
PDCs were divided into 2 groups: PDC-IRR (52 canines) and PDC-No-IRR (55 canines). The 3 groups were
compared, and the following variables were measured: canine follicle size, contact with adjacent incisors,
associated dental abnormalities, sector analysis, canine vertical relation to adjacent root, lateral incisor
angulation and inclination, canine angulation and distance to reference planes (dental midline, midpalatal
suture, occlusal plane, pterygoid vertical plane, and lateral incisor), and space available for canine in the
dental arch. Discriminant functional analysis was used to produce a discriminant function equation to predict
PDC-IRR. Results: Root resorption affected 74% of lateral incisors adjacent to PDCs and 25.5% of lateral in-
cisors adjacent to NDCs. IRR was located lingually in 41% of PDCs and in the mid and apical thirds in 89%.
In the PDC-IRR group, 94.2% of canines were in contact with adjacent roots compared with 23.6% in the
PDC-No-IRR group (P \0.001). Canine follicle size was .2 mm in 42% of PDC subjects. Overall mean value
of follicle width in PDC canines was 1.79 6 1.06 mm. Peg-shaped lateral incisors were recorded in 19% of
PDC subjects compared with 4% in NDCs (P 5 0.012). The stepwise analysis using cone-beam computed
tomography records produced a discriminant function based on 3 variables. The analysis correctly predicted
the outcome in 83% of subjects. The variables contributing to the prediction equation were canine contact
with adjacent incisors, size of canine dental follicle, and the presence of peg-shaped lateral incisor.
Conclusions: Canines in contact with adjacent incisor roots was the only risk factor detected for PDC-IRR.
Very good predictive discrimination (83%) emerged for PDC-IRR subjects. Predictors of PDC-IRR were
canine contact with adjacent incisor, size of canine dental follicle, and presence of peg-shaped lateral incisor.
(Am J Orthod Dentofacial Orthop 2020;157:80-90)

T
he displaced or ectopic canine is the one diverging
from its normal path of eruption, either to erupt in
an unusual position or to become impacted
a
Division of Orthodontics, Department of Preventive Dentistry, Faculty of
Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
b
Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Elham S. Abu Alhaija, Division of Orthodontics,
Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of
Science and Technology, PO Box 3030, Irbid 22110, Jordan; e-mail, elham@
just.edu.jo.
Submitted, May 2019; revised, July 2019; accepted, August 2019.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.08.008
80
buccally or palatally.1 The reported prevalence of maxil-
lary canine displacement or impaction varies between
different populations. It ranges from 1% to 5%.2-4
Numerous sources in the literature suggest that the
majority of ectopic canines in Caucasians were palatal.5,6
The specific etiology behind palatally displaced
maxillary canines (PDC) is unknown.7 Two broad the-
ories exit: the guidance theory and the genetic theory.8
Guidance theory of palatal canine displacement suggests
that environmental factors give rise to palatal displace-
ment of canines such as congenitally missing lateral
incisor, supernumerary teeth, odontome, and other local
factors that interfere with its eruption path. In contrast,
the genetic theory suggests that it is a genetically
Alemam et al
predetermined anomaly, with polygenic, multifactorial
inheritance. All causative elements and associated phe-
nomena such as long path of eruption, abnormal posi-
tion of tooth bud, hard tissue obstructions, soft tissue
lesions, and anomalies are etiologically construed as
genetic, including the aberrant canine itself.9
In addition to the orthodontic sequela and its conse-
quences on the occlusion, several complications can
result from maxillary canine ectopia. The most common
serious complication is external root resorption of inci-
sors, and so often, it is underestimated or missed.
Once diagnosed on plain radiography, the resorption
would be in an advanced stage.
Incisor root resorption associated with maxillary
canine is common in ectopic cases. Both buccally and
palatally displaced canines can cause adjacent root
resorption.10 Resorption of lateral incisor can also be
caused by normally erupted maxillary canines.11
Radiological examination is an essential part of the
diagnostic process of impacted canines and associated
incisor root resorption. Serrant et al12 suggested that
cone-beam computed tomography (CBCT) is more accu-
rate than either horizontal or vertical parallax for the
localization of ectopic maxillary canine teeth. CBCT is
capable of providing accurate, submillimeter-resolution
images with isotropic voxels, allowing 3-dimensional
(3D) visualization of the complex maxillofacial region.13
The reported prevalence of IRR associated with PDCs
has increased over the time, because the methods for its
radiographic detection has got more advanced. With the
application of a 3D imaging, it reached a percentage of
48%.14 Recent CBCT studies reported 25%-67.6% prev-
alence for lateral incisor and 5%-18% for central incisor
roots resorption adjacent to PDCs in Caucasians.1,15-17
The true etiology of incisor root resorption associated
with palatally displaced canines (PDC-IRR) is not well
understood. However, the removal of the canine seems
to stop progression of resorption even in severe cases.10
Therefore, physical proximity of canine and/or its follicle
seem to be the most likely risk factors although results
contradictory.1,11,15,18 Ericson and Kurol19 found that
IRR cases showed a more advanced dental development,
a more medial canine position in the dental arch and a
slightly more mesial horizontal path of eruption. With
the use of 3D imaging, the exact contact relationship
of the canine crown follicle and the adjacent root can
be assessed accurately. Some studies explored the asso-
ciation of IRR with PDC canine follicles larger than
3 mm. They reported no relationship between resorption
and enlarged dental follicles.14,15,20 On the other hand,
Chaushu et al1 reported that dental follicles wider than
2 mm increased the risk by 8.3-fold compared with
normal dental follicles.
American Journal of Orthodontics and Dentofacial Orthopedics
81
In the present investigation, CBCTs were used to
study PDC-IRRs. The aims were to report on the preva-
lence and characteristics of PDC-IRRs, to compare
PDC-IRR and PDC-No-IRR groups, to identify predictors
for PDC-IRR, and to produce a valid PDC-IRR prediction
model using discriminant function analysis.
MATERIAL AND METHODS
Ethical approval was obtained from Institutional Re-
view Board of Jordan University of Science and Technol-
ogy (JUST). The sample of this study was collected over a
period of 2 years by 3 means: database search (existing
CBCT that were taken for diagnostic purposes as part
of comprehensive orthodontic treatment), referrals by
fellow dentists and orthodontists, and screening
school-aged children and referring them for further ex-
amination and treatment at orthodontic clinics/JUST.
All patients in the study had been referred for CBCT
imaging after clinical and radiographic (panoramic or
periapical radiographs) examination. The CBCT images
taken between January 2010 to October 2016) were
screened for the presence of PDCs. Inclusion criteria
were nonsyndromic and noncleft patients, with no pre-
vious orthodontic treatment involving maxillary incisors,
no contributing history of trauma; no root canal treat-
ment and no presence of cysts or other pathologies.
University students and school-aged children were
screened (clinical examination, palpation) for the pres-
ence of maxillary PDC. Subjects suspected to have PDC
were referred to the radiology department, where local-
ization of canine was carried out radiographically (2 pos-
terioanterior radiographs were taken). If posterioanterior
radiographs showed a palatal displacement along with
some overlapping of the canine over the adjacent incisor,
a CBCT image was taken as a part of orthodontic pre-
treatment records. If those subjects were able to pay
the cost of orthodontic treatment, they were referred
to postgraduate orthodontic clinics for fixed appliance
treatment.
Sample size for this study was calculated using the
formula,21 n 5 Z2 (1-a) p (1-p)/d2, where Z is the
2-sided Z value required for the 90% confidence interval,
which is equal to 1.645, p is the prevalence of maxillary
lateral incisor root resorption, which was estimated from
previous study (P 5 25%),15 and d is the allowable error
(0.1). Therefore, the sample size for each group calcu-
lated using the above formula was 51 canines.
Canines were determined to be displaced or not dis-
placed palatally, as follows: PDCs—canines appearing
palatal to a line connecting the roots of adjacent teeth
at any level of canine crown (n 5 107), and nondisplaced
canines (NDCs)—canines that are normal and erupted as
should in the dental arch (n 5 51).
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82 Alemam et al

Table I. Methods used to measure root resorption, canine follicle width, proximity and contact relationship presence
of dental anomalies and sector analysis
Variables Method
Root resorption
Severity of IRR14 No resorption. Intact root surfaces, cementum layer may be lost.
Mild resorption. Up to half of the dentine thickness to the pulp
Moderate resorption. Resorption midway to the pulp or more, pulp lining being unbroken
Severe resorption. Pulp is exposed by the resorption
Location of IRR Cross-sectional. Recorded as distal, mesial, buccal, lingual or distolingual
Vertically. Recorded at the deepest point corresponding to cervical, middle, or apical thirds of
incisor root.
Extent of IRR Registered whether resorption extended for less than a third of root length, one third to half, or
more than a half the root length.
Canine follicle width. Graded in 1-mm Grade 1—follicle width is 0-1 mm
intervals, in accordance with Grade 2—follicle width is 1-2 mm
Chaushu et al1 Grade 3—follicle width is 2-3 mm
Grade 4—follicle width is 3 mm or more.
Proximity and contact relationship Location of contact on the cross-section of the adjacent root was recorded to be distal, mesial,
buccal, lingual or distolingual.
Presence of dental abnormalities Agenesis of teeth, supernumeraries, impacted teeth other than third molars, peg-shaped lateral
incisors were recorded.
Sector analysis. In accordance with Sector I. Cusp tip distal to a line tangent to the distal aspect of lateral incisor. It is the reference
Lindauer et al22 for normality as it corresponds to the primary canine.
Sector II. Mesial to sector I, with the cusp tip distal to midline of lateral incisor.
Sector III. Mesial to sector II, with the cusp tip distal to central incisor distal aspect.
Sector IV. Mesial to sector II, with the cusp tip distal to midline of central incisor.
Sector V. Any position mesial to sector IV.

IRR was registered by sliding along the incisor root
in cross-sectional and longitudinal views (both perpen-
dicular to the tooth's long axis). Any loss of root struc-
ture, that is, clear demarcated crater or irregular
surface loss (depression) compared with areas above
and below was recorded. The degree of IRR severity
was determined according to Ericson and Kurol14 criteria
as no resorption, mild, moderate, and severe resorption
(Table I22; Fig).
To determine a clearly defined cutoff point in
choosing the PDC-IRR group, subjects had to show
moderate or severe root resorption, as this could be iden-
tified more clearly and with a higher sensitivity. Mild
resorption was grouped with the PDC-No-IRR group to
overcome any error that may affect the diagnostic ca-
pacity of the CBCT images in cases of mild resorption.
Accordingly, PDCs were divided into 2 groups: group 1
(PDC- IRR)—PDCs associated with moderate to severe
IRR (52 canines), and group 2 (PDC-No-IRR)—PDCs
associated with no or mild IRR (55 canines).
A total of 82 Caucasian patients (19 male and 63 fe-
male) were included in the study. Age ranged from 14 to
31 years with an average age of 20.84 6 8.54 years. PDC
was present bilaterally in 25 patients and unilaterally in
the remaining patients (24 patients on the right side and
33 on the left side).
A total of 51 patients with unilateral PDC had nor-
mally erupted canines on the contralateral side (11
male and 40 female; average age 21.79 6 5.54 years).
These canines were included in the study, analyzed,
and served as a control (NDC). The remaining 6 unilateral
PDC patients had buccally displaced canines on
the contralateral side, and thus these canines were
excluded.
Two similar CBCT apparatuses were used. They were
CS 9500 Cone Beam 3D System (Carestream Health, Ro-
chester, NY) with a flat panel detector. The CBCT images
were 0.2 mm slices of a medium field of view, where the
maxillofacial area was examined at a tube voltage of
90 kV, a tube current of 10 mA, and exposure time of
8.01 seconds. The imaging area was a cylinder with a
height of 15 cm and a diameter of 9 cm providing
0.2 mm cubic voxels.
Examinations were performed by 360 rotations with
patient in an upright position and Frankfort horizontal
plane parallel to ground. CBCT orthogonal views were
used for linear measurements. 3D reconstruction view
was used to aid in assessing peg-shaped laterals. Oblique
views passing through the long axis of canines and inci-
sors were used to evaluate tooth length, IRR, and bucco-
lingual and mesiodistal widths of crowns. Dental
pantomographic reconstruction view was used to record
some angular measurement, peg-shaped laterals, sector
and overlap. Custom focal trough (image layer) selection
for panoramic reconstruction was symmetrical and coin-
ciding with maxillary teeth for all patients. Dental

January 2020  Vol 157  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Alemam et al
Figure. Severity of incisor root resorption: A, mild resorption; B, moderate resorption; and C, severe
resorption.
pantomographic reconstructed images were examined
at a thickness of 15-30 mm.
Tables I and II present the variables included in the
study and methods used to measure them.
CBCT images were evaluated throughout a period of
a month, by one examiner (AA). All images were evalu-
ated in dimmed light using a screen with
1920 3 1200 pixels. Measurements were made using
installed CBCT software, CS 3D imaging viewer (CS 3D
imaging viewer, 3.2.9, Carestream Health). When neces-
sary, the window settings were adjusted to optimize the
images for evaluation and zoomed in as much as needed
for a careful evaluation.
A random sample of 10 CBCT images (10% of total
sample) where re-evaluated after 1-month interval. All
measurements were repeated by the same examiner in
the same conditions to test intraexaminer reliability.
Kappa test was used for the categorical data and Dahl-
berg error for the double measurement was used to
calculate the standard error of the method. Kappa values
were above 92% for all the measured categorical vari-
ables. Dahlberg error ranged from 0.16 for canine
angulation to occlusal plane to 0.018 mm for canine
distance to occlusal plane.
Statistical analysis
Statistical analysis was performed with the use of the
Statistical Package for Social Science computer software
(version 23, SPSS Inc, Chicago, Ill). The Shapiro-Wilk test
American Journal of Orthodontics and Dentofacial Orthopedics
83
was used to assess normality of numerical data. The
values were $0.05, indicating the data was normal.
Descriptive statistics were calculated for all the
measured variables for each group. Differences between
groups were assessed using ANOVA and chi-square test
for linear and categorical data, respectively. Bonferroni
post-hoc multiple comparisons test was used for numer-
ical data to identify differences between the groups. The
level of significance was set at P #0.05. Discriminant
functional analysis (stepwise analysis) was used to pro-
duce a discriminant function score. The function was
statistically significant at P \0.001. The discriminant
function equation derived from original sample was
applied to a fresh sample of 10 patients (8 female and
2 male; average age 18.52 6 3.40 years) who fulfilled
the same selection criteria as the main sample. PDCs
were present bilaterally in 2 patients and unilaterally in
the remaining subjects.
The data for each patient were entered in the equa-
tion. A positive discriminant score indicated prediction
of IRR. Percentage of correct prediction was calculated.
RESULTS
Sex differences in PDC-IRRs were not detected
(c2 5 0.190, P value 5 0.663). A total of 111 maxillary
incisors (92 laterals and 19 centrals) had some degree of
root resorption associated with canine eruption
(Table III). All 19 resorbed central incisors belonged to
the PDC group. Root resorption affected 25.5% of lateral
January 2020  Vol 157  Issue 1
84
Table II. Methods used to measure canine vertical relationship, lateral incisor- and canine-related variables, canine
angulation, and canine distance to reference planes
Variables
Canine vertical relationship to adjacent incisor root
Lateral incisor-related variables
Canine-related variables
Canine angulation to reference planes
Canine distance to reference planes
DPT, dental pantomographic; OP, occlusal plane.
incisors adjacent to NDCs (P \0.001). Root resorption
affected 74% of lateral incisors adjacent to PDCs,
together with 18% of central incisors. IRR in the PDC
group was significantly higher than the NDC group
(P \0.001).
In PDC subjects, IRR was located lingual, distal, dis-
tolingual, and mesial in 41%, 26%, 19%, and 14% of
cases. Vertically, IRR was located in the mid and apical
thirds in 89% of cases. In 78.5% of cases, the extent
of IRR was more than one third of root surface. In
NDC, IRR was located distal in all cases. Extent of IRR
was less than one half of root surface in all cases.
PDC dental follicle width had a mean value of
1.63 6 1.02 mm in the IRR group compared with
1.95 6 1.08 mm in the PDC-No-IRR group
(P 5 0.173). The overall mean value of follicle width
in PDC canines was 1.79 6 1.06 mm. In PDC subjects,
canine follicle was grade 1 in 21.5% (15% and 27% in
IRR and No-IRR groups, respectively), grade 2 in 36%
(42% and 31% in IRR and No-IRR groups, respectively),
grade 3 in 29% (25% and 33% in IRR and No-IRR
groups, respectively), and grade 4 in 13% of cases
January 2020  Vol 157  Issue 1
Alemam et al
Method
Recorded as its tip corresponds to cervical, mid, or apical third of adjacent root.
Mesiodistal and buccolingual width of the lateral incisor
Lateral incisor length. Measured on oblique view in mm
Mesiodistal tipping of lateral incisor. Angulation to midline measured on coronal
and DPT view.
Buccolingual inclination of lateral incisor. Angulation to occlusal plane measured on
sagittal view
Mesiodistal and buccolingual width of the canine.
Canine length. Measured on oblique view in mm
Angle to midline (Alpha angle): Angulation of canine to midline measured on the
coronal view.
Angle to occlusal plane (Delta angle): Angulation of canine to OP, measured on the
sagittal view.
Angle to midpalatal suture (Gamma angle): Angulation of canine to midpalatal
suture measured on the axial view.
Canine angulation to lateral incisor (Beta angle): Angle between canine long axis and
lateral incisor, measured on coronal view.
Canine distance to occlusal plane: Vertical distance from canine tip to OP in mm,
measured on the sagittal view. Canines below the plane were given a negative
value.
Canine distance to dental midline: Horizontal distance from canine tip to midline in
mm, measured on the coronal view. Canines crossing the midline were given a
negative value.
Canine distance to midpalatal suture: Horizontal distance from canine tip to
midpalatal suture in mm, measured on the axial view. Canines crossing the suture
were given a negative value.
Canine distance to pterygoid vertical (d4): perpendicular distance from the distal
aspect of canine crown to pterygoid vertical plane. Pterygoid vertical plane is a
perpendicular tangent to the posterior border of the pterygomaxillary fissure.
(17% and 9% in IRR and No-IRR groups, respectively).
The differences between the PDC groups were not sig-
nificant (c2 5 4.64, P 5 0.200) (Table IV).
More than one half (58%) of PDCs were in contact
with the adjacent incisor. In PDC-IRR group, 94.2% ca-
nines were in contact with adjacent roots compared with
23.6% in PDC-No-IRR group, (c2 5 54.662, P \0.001).
Peg-shaped laterals were recorded in 19% of subjects
of PDC (17% and 20% in IRR and No-IRR groups,
respectively) compared with 4% in NDC (c2 5 6.287,
P 5 0.012). Other anomalies included missing teeth
(5% in NDC and 6% in PDC [8% in IRR and 2% in No-
IRR]), supernumeraries (4% in NDC and 2% in PDC
[2% in IRR and 5% in No-IRR]), and other impacted
teeth (17% in NDC and 6% in PDC [20% in IRR and
14% in No-IRR]). No statistical differences between
PDC-IRR and PDC-No-IRR groups were found
(c2 5 0.576, P 5 0.278) (Table IV).
In the PDC-IRR group, 23% of cases were in sector V,
10% in sector IV, 17% in sector III, 23% in sector II, and
27% in sector I. In the PDC-No-IRR group, 9% of cases
were in sector V, 14.5% in sector IV, 29% in sector III,
American Journal of Orthodontics and Dentofacial Orthopedics
Alemam et al 85

Table III. Frequency of IRR in the studied groups (PDC and NDC)
Lateral incisors IRR severity Central incisors IRR severity

Group (number of canines) None Mild Moderate Severe Total None Mild Moderate Severe Total IRR
Bilateral PDC (50) 12 (24) 16 (32) 8 (16) 14 (28) 38 (76) 46 (92) 2 (4) 0 (0) 2 (4) 4 (8)
Unilateral PDC (57) 16 (28) 14 (24.5) 10 (17.5) 17 (30) 41 (72) 42 (74) 5 (9) 2 (3) 8 (14) 15 (26)
Total PDC (107) 28 (26) 30 (28) 18 (17) 31 (29) 79 (74) 88 (82) 7 (7) 2 (2) 10 (9) 19 (18)
NDC (51) 38 (74.5) 6 (12) 7 (14) 0 (0) 13 (25.5) 51 (100) 0 (0) 0 (0) 0 (0) 0 (0)
Note. Values are n (%) unless otherwise specified.

13% in sector II, and 31% in sector I. No statistical dif-
ferences between PDC-IRR and PDC-No-IRR groups
were found (c2 5 7.53, P 5 0.110) (Table IV).
Canine vertical relation to the adjacent incisor's root
showed that canines in the PDC group were located in
the cervical third. They represented 53.8% of PDC-IRR
group and 41.8% of PDC-No-IRR group (P 5 0.075).
Means, standard deviations, standard error of the
means, mean differences, and P values for lateral
incisor- and canine-related variables, canine angulation,
and canine distance to reference planes in the studied
groups are shown in Tables V and VI.
In PDC, 62% of cases (65% in IRR and 58% in No-IRR
groups) presented with an alpha angle of .30 , 30%
(31% in IRR and 29% in No-IRR) with an alpha angle
of 15 -30 , and 8% (4% in IRR and 13% in No-IRR
groups) has an alpha angle #15 (c2 5 0.127;
P 5 0.721). In NDC, 90% presented with an alpha angle
of #15 . The difference between the PDC and NDC
groups was significant (c2 5 103.78, P 5 0.001).
The differences between canine- and lateral incisor–
related variables were not significant between the PDC-
IRR and PDC-No-IRR groups. However, they differed
significantly when compared with the NDC group.
The stepwise analysis with the use of CBCT records
produced a discriminant function based on 3 variables
(Table VII). The function was statistically significant at
P \0.001. The analysis correctly predicted the outcome
in 83% of subjects. The variables contributing to the
prediction equation were canine contact with adjacent
incisors, size of the canine dental follicle, and the pres-
ence of a peg-shaped lateral incisor. A positive discrim-
inant score indicates predicted IRR- PDC. The equation
is.
prediction function 5 –1.886 1 (2.527 3 V1) 1
(0.325 3 V2) 1 (–0.903 3 V3).
where V1 is contact with adjacent incisors (V1 5 0 if
no contact with adjacent incisor and V1 5 1 if contact
with adjacent incisor), V2 is follicle size measured in
mm, and V3 is the presence of a peg-shaped lateral
incisor (V3 5 0 if a peg-shaped lateral incisor is not pre-
sent, and V3 5 1 if a peg-shaped lateral incisor is
present). When the discriminant function equation was
applied to the validation sample, correct prediction
occurred in 100% of the sample.
Because the right and left sides of the bilateral PDC
group were entered into the statistical analysis as inde-
pendent variables and to exclude the possibility of get-
ting IRR prediction inflation, a correlation test between
the 2 sides of the bilateral PDC group was performed
for the variables that contributed to the prediction
model. No significant correlations between right and
left sides of the above variables were detected
(P .0.05).
DISCUSSION
It remains a mystery why some ectopic canines cause
IRR and others with the same position do not. Few pub-
lished studies aimed to investigate resorption associated
with canine ectopia have been conducted.1,10,11,14-16,18
Some of them tested the association between
resorption and position of canine in the arch and
identified different risk factors.1,11,15,16
In most of these previous studies, buccal displaced
canines (BDCs) and PDCs were combined together
when assessing maxillary canine-linked IRR phenome-
non.1,11,14-16,18 Because positioning and angulation of
BDCs and PDCs vary, the present study excluded BDCs
to isolate factors associated with PDC-IRR only.
It has been reported that ethnicity affects the preva-
lence of PDC, where Europeans had a higher prevalence
of palatal position.18 There are some reported differ-
ences in prevalence and features of IRR between Cauca-
sians and Asian populations.11 To exclude any effect of
ethnicity on IRR, all patients included in this study were
Caucasian.
CBCT images were used to detect IRR associated with
PDCs, which was in line with the recommendations of
the American Academy of Oral and Maxillofacial
Radiology.23 The use of CBCT to diagnose IRR was
emphasized by Haney et al,24 who concluded that 2-
dimensional and 3D images of impacted maxillary ca-
nines can produce different diagnoses and treatment
plans owing to lack of congruence (36%) in the

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86 Alemam et al

Table IV. Frequency distribution of peg-shaped lateral incisor and other dental anomalies, canine follicle size, and
canine positions in sectors among the studied groups
PDC-IRR PDC-No-IRR PDC NDC
Normal-shaped lateral incisor 43 (82.7) 44 (80) 87 (81.3) 49 (96.1)
Peg-shaped lateral incisor 9 (17.3) 11 (20) 20 (18.7) 2 (3.9)
c2 (P value) 1.103 (P 5 576) 6.287 (P 5 0.012)*
Other anomalies
No dental anomaly 37 (71.2) 44 (80.0) 81 (75.7) 44 (86.3)
Other impacted teeth 10 (19.2) 7 (12.7) 17 (15.9) 3 (5.9)
Supernumerary teeth 1 (1.9) 3 (5.5) 4 (3.7) 1 (2.0)
Congenitally missing teeth 4 (7.7) 1 (1.8) 5 (4.7) 3 (5.9)
c2 (P value) 3.853 (P 5 0.278) 3.664 (P 5 0.300)
Canine follicle size
0-1 mm (grade 1) 8 (15.4) 15 (27.3) 23 (21.5) 51 (100)
1-2 mm (grade 2) 22 (42.3) 17 (30.9) 39 (36.4) 0 (0)
2-3 mm (grade 3) 13 (25) 18 (32.7) 31 (28.9) 0 (0)
$3 mm (grade 4) 9 (17.3) 5 (9.1) 14 (13.1) 0 (0)
c2 (P value) 4.64 (0.200) 85.49 (P \0.001)***
Canine position in sectors
Sector I 14 (26.9) 19 (34.5) 33 (30.8) 51 (100)
Sector II 12 (23.1) 7 (12.7) 19 (17.8) 0 (0)
Sector III 9 (17.3) 16 (29.1) 25 (23.4) 0 (0)
Sector IV 5 (9.6) 8 (14.5) 13 (12.1) 0 (0)
Sector V 12 (23.1) 5 (9.1) 17 (15.9) 0 (0)
c2 (P value) 7.53 (0.110) 64.47 (P \0.001)***
Note. Values are n (%) unless otherwise specified.
*P \0.05; ***P \0.001.

Table V. Means, SD, SE, mean differences, and P values for lateral- and canine-related variables in the studied groups
PDC-IRR PDC-No-IRR
group group Difference, PDC group NDC group Difference,
Variable n 5 52 n 5 55 mean (SE) P value n 5 107 n 5 52 mean SE
Lateral incisor–related
Mesiodistal width 6.42 (0.56) 6.57 (0.71) 0.07 (0.12) 1.000 6.46 (0.63) 6.49 (0.61) 0.04 0.11 0.735
Buccolingual width 6.43 (0.60) 6.47 (0.64) 0.04 (0.11) 1.000 6.45 (0.61) 6.54 (0.50) 0.09 0.10 0.374
Lateral incisor length 22.43 (1.91) 22.36 (2.59) 0.07 (0.42) 1.000 22.39 (2.24) 22.40 (1.85) 0.01 0.37 0.984
Mesiodistal tipping 4.36 (8.94) 2.02 (10.63) 2.33 (1.74) 0.546 3.24 (9.81) 4.08 (6.51) 1.34 9.96 0.001***
Buccolingual 67.51 (10.49) 64.26 (11.28) 3.25 (1.89) 0.261 65.96 (10.94) 61.31 (6.29) 4.66 1.40 0.001***
inclination
Canine-related
Mesiodistal width 7.7 (0.43) 7.66 (0.38) 0.04 (0.08) 1.000 7.68 (0.41) 7.54 (0.43) 0.15 0.07 0.040*
Buccolingual width 7.88 (0.50) 8.06 (0.47) 0.18 (0.10) 0.238 7.97 (0.49) 8.14 (0.60) 0.17 0.09 0.058
Canine length 24.96 (2.25) 24.96 (2.53) 0.06 (0.47) 1.000 24.93 (2.38) 25.61 (2.51) 0.68 0.41 0.102
Note. Values are mean (SD) unless otherwise specified.
SD, standard deviation; SE, standard error of the mean.
*P #0.05; ***P \0.001.

perception of root resorption of adjacent teeth.
Although CBCT images were taken by 2 machines in 2
different locations, they were of the same manufacturer
(Carestream).
Reading the CBCT in this study was different in that
oblique views were used, allowing the true width of the
follicle to be recorded perpendicular to the long axis of
the canine and not on the axial view. Clearly defined cut-
off points were established in choosing the PDC- IRR
group. Mild resorption was grouped with PDC-No-IRR
group to overcome any error that may affect the diag-
nostic capacity of the CBCT images in cases of mild
resorption.
A positive association between sex and IRR was not
detected in this study. This was in agreement with Cer-
nochova et al,25 who found no significant relationship
between the occurrence of resorption and sex, and in
contrast to other studies.1,14,17 In the present study,

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Alemam et al 87

Table VI. Means, SD, SE, mean differences, and P values for canine angulation and its distance to reference planes in
PDC-IRR, PDC-No-IRR, and NDC groups
Mean
PDC- PDC-No- difference PDC Mean
Variable IRR group IRR group (SE) P value group NDC group difference (SE) P value
Canine angulation in
orthogonal planes
Angle to midline (alpha) 26.65 (19.34) 29.23 (17.24) 2.57 (3.15) 1.000 27.89 (18.32) 6.41 (7.53) 34.30 (2.15) \0.001
Angle to occlusal 56.35 (15.11) 52.67 (19.00) 3.67 (2.80) 0.573 54.56 (17.13) 68.06 (5.40) 13.50 (2.48) \0.001
plane (delta)
Angle to midpalatal 35.75 (25.08) 42.13 (18.83) 6.38 (4.54) 0.487 38.91 (22.33) 19.19 (26.05) 58.10 (4.46) \0.001
suture (gamma)
Angle to lateral 42.44 (19.80) 42.53 (21.60) 0.09 (3.66) 1.000 42.48 (20.59) 1.83 (3.26) 40.66 (4.32) \0.001
incisor (beta)
Canine distance
to reference planes
Canine to occlusal 8.95 (4.33) 9.65 (4.14) 0.7 (0.68) 0.916 9.29 (4.23) 0.05 (0.84) 9.34 (0.43) \0.001
plane (d1)
Canine to dental 7.5 (4.15) 6.44 (4.23) 1.06 (0.77) 0.516 6.99 (4.20) 15.73 (3.39) 8.74 (0.68) \0.001
midline (d2)
Canine to 8.25 (4.70) 6.68 (4.25) 1.57 (0.77) 0.129 7.49 (4.53) 15.77 (2.51) 8.28 (0.57) \0.001
midpalatal suture (d3)
Canine to 39.77 (4.30) 39.02 (3.99) 0.754 (0.83) 0.369 39.40 (4.15) 44.08 (4.73) 4.67 (0.78) \0.001
pterygoid vertical (d4)
Note. Values are mean (SD) unless otherwise specified.
SD, standard deviation; SE, standard error of the mean.

the sex factor must be considered with caution owing to
the high female-to-male ratio. The low number of male
subjects included in this study may have affected the re-
sults, and it was probably because male subjects were
less willing to undergo lengthy orthodontic treatment.
Prevalence of root resorption was higher in incisors
adjacent to PDCs than NDCs. Three fourths of lateral in-
cisors adjacent to PDCs were affected by IRR. Previously
reported prevalence of resorption in incisors adjacent to
palatal impacted canines varied. It was found to be 39%
in Caucasians and 27% in Asians.11,14,18 In contrast, only
1 published study reported on the prevalence of IRR of
lateral incisor adjacent to NDCs, describing a 3%
prevalence of IRR in a Chinese population.11 The differ-
ences in the prevalence may be due to the different ways
used to read the CBCT images.
In the present study, root resorption affected 74% of
lateral incisors and 18% of central incisors adjacent to
PDCs compared with 25.5% of lateral incisors resorption
adjacent to NDCs. This was in agreement with other
studies, which reported that the most affected tooth is
always the lateral incisor, followed by the central
incisor.14,26 One finding regarding PDC-IRR is that
more central incisor root resorption was detected in
unilateral compared with bilateral PDC subjects, which
we could not explain from the findings of the present
study.
Table VII. Constant and discriminant function coeffi-
cients for IRR-PDCs
Unstandardized canonical
Predictive variable discriminant function coefficient
Constant 1.886
Canine contact with 2.527
adjacent incisors
Size of canine dental follicle 0.325
Presence of 0.903
peg-shaped lateral incisor
In the present study, the most common location on
the root cross section was lingual, which can be
explained by the palatal position of displaced canines.
The second most common location was the distal sur-
face. This was in agreement with the report by Ericson
and Kurol.14 Based on this finding, the necessity of a
3D evaluation is evident in most cases where the resorp-
tion lesion is located lingually and in the middle third of
the root.
The results of this study were consistent with those of
Ericson and Kurol14 and Hadler-Olsen et al,16 who re-
ported IRR in Caucasians was located in the middle third
of the incisors, followed by the apical third; although,
Yan et al11 reported that IRR was present predominantly
in the apical third followed by the middle third. However,
the latter study included BDCs and the subjects were

American Journal of Orthodontics and Dentofacial Orthopedics January 2020  Vol 157  Issue 1
88
Asians. Asians are reported to have a lower incidence of
PDCs than Caucasians.11,27
In our study, the most common degree of root
resorption was severe, followed by mild. Pulpal involve-
ment was more prevalent in the centrals, compared
with laterals, which was in agreement with other
studies.11,14 Ericson and Kurol14 observed that 60%
of the resorption of the lateral incisors and 43% of
that of the central incisors in their sample had pulpal
involvement.
The majority of canines in the PDC-IRR group were in
contact with adjacent incisor roots, compared with 23%
in the PDC-No-IRR group. The physical proximity of the
canine to resorbed roots supports the theory that resorp-
tion is due to physiological pressure rather than an
enlarged follicle.28 Nevertheless, this does not explain
why some canines contacting the adjacent roots did
not cause any resorption. Displacement of the root
may have resulted from those canines contacting but
not resorbing adjacent roots, and thus, moving the
root away.
The canine angulations and canine distances to
reference planes were not different between the PDC-
IRR and PDC-No-IRR groups. This was in disagreement
with Ericson and Kurol,14 who found that the risk of
resorption increases by 50% when the eruption inclina-
tion (angle alpha) exceeds 25 and increases by 50%
when the eruption inclination (angle beta) exceeds 28
compared with controls. Also, Ericson and Kurol14
confirmed that resorption of the lateral incisors during
ectopic eruption of the maxillary canine is more probable
when the tooth erupts medially to the long axis of adja-
cent incisor and is inclined at an angle of 25 or more to
the midline of the jaw.
Canine and lateral incisor widths and lengths were
not significantly different between the PDC and NDC
groups, except for the mesiodistal canine width, which
was significantly less in the NDC group. However, the
mean difference of 0.15 mm is unlikely to be of clinical
significance, and it is highly unlikely to contribute to
palatal displacement of the wider canine. This was in
disagreement with some authors who reported no corre-
lation between mesiodistal canine width and PDCs27 and
others who reported that mesiodistal canine width was
narrower in the PDC.28
The clinical problem addressed in this study was of
predicting incisor root resorption associated with
PDCs. Previous studies to investigate IRR associated
with canine ectopia were conducted. They identified
different risk factors but failed to validate the proposed
predictors.1,11,16,19
Discriminant function analysis was used in this study
to derive an equation to distinguish 1 group of subjects
January 2020  Vol 157  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Alemam et al
from another and in the present context, will distinguish
between PDC-IRR and PDC-No-IRR. To avoid the possi-
bility of giving unrealistic accuracy in prediction, the
discriminant function equation was tested against a
fresh sample separate from the material from which
the equation was derived.16
None of the variables registered on the panoramic
view or observed clinically were retained in the final
discrimination equation, with the exception of 1 variable
(peg-shaped lateral) that served as a negative predictor.
This is not helpful for clinicians in reducing the need for
further CBCT scans in cases of PDCs.
In this study, canine contact with an adjacent incisor
root was the strongest predictor of IRR. This was in
agreement with Ericson and Kurol,14 Yan et al,11 Lai
et al,15 and Liu et al18 who investigated this relationship
using CBCT images.
Yan et al11 reported that physical proximity (#1 mm)
between the impacted canine and an adjacent root is the
most important predictor for root resorption. In contrast,
Preda et al20 used CT imaging and reported that root
resorption was demonstrated in only one third of the
cases where there was contact between impacted maxil-
lary canines and incisor roots. However, a very small
sample in the latter study may be the reason (fewer
than 20 patients). The consistent finding of physical
proximity of the canine to resorbed roots supports the
theory that resorption is due to physiological pressure.29
The size of canine dental follicle contributed to the
prediction of IRR in our study. This was in disagreement
with previous studies, which reported no relationship be-
tween resorption and enlarged dental follicles of
impacted canines with the use of 3D images.14,16,20,29
The finding of this study was in agreement with
Chaushu et al,1 who used a grading system for
measuring canine follicles and found that dental follicles
wider than 2 mm increased the risk by 8.3-fold compared
with normal dental follicles. Follicle width, as the largest
distance from the crown of the maxillary canine to the
periphery of the follicle, was measured on an oblique
section through the long axis of the canine in the present
study. This should be more accurate than measuring the
follicle width on the axial view (especially in more hori-
zontal cases), as done by all of the earlier studies.
Dental anomalies were not found to be associated
with IRR. Nevertheless, when peg-shaped laterals were
considered alone, they acted as negative predictors of
IRR and were associated with nonresorption cases. This
was in partial agreement with Alqerban et al17 who sug-
gested that detection of abnormality including a peg-
shaped lateral was a predictor for IRR. This emphasizes
the previous finding that canine proximity and contact
is a major contributing factor for IRR. In the presence
Alemam et al
of a small lateral, contact with lateral incisor root is less
likely.
The validation sample used to test the predictive ac-
curacy of the PDC-IRR discriminant equation was sepa-
rate from the material from which the equation was
derived but was selected using the same selection criteria
as the main sample. The result was excellent predictive
capability reaching 100%. This, however, must be inter-
preted with caution, because of the small validation
sample used.
Because canine contact with adjacent incisor
root was the only variable that differed between the
PDC-IRR and PDC-No-IRR groups, prescription
of CBCT to evaluate the possibility of the resorption of
the adjacent teeth when preliminary evaluation of pano-
ramic radiograph shows that there is overlapping be-
tween the lateral incisor and the canine is recommended.
Limitations of this study include a small sample size
and a high female-to-male ratio. More male subjects
should be included in future studies. Also, the number
of PDC subjects in the validation sample is considered
small. Furthermore, some patients had a bilateral PDC
and the 2 sides were entered into the statistical analysis
as independent variables.
CONCLUSIONS
1. Root resorption is more common in PDCs compared
with NDCs.
2. Canine dental follicle size was similar in PDC-IRR
and PDC-No-IRR groups.
3. Canine angulation and proximity to midline were
similar in PDC-IRR and PDC-No-IRR groups.
4. Predictors of PDC-IRR were canine contact with
adjacent incisor, size of canine dental follicle, and
presence of peg-shaped lateral incisor.
5. Very good predictive discrimination (83%) emerged
for PDC-IRR subjects.
6. All IRR-PDC cases were correctly predicted when the
derived discriminant equation was tested on a fresh
sample.
ACKNOWLEDGMENTS
This study was supported by the Deanship of
Research, Jordan University of Science and Technology,
grant number 170/2015.
The authors express their gratitude to Dr Abeer Al Ha-
didi for her expertise and feedback and to Dr Irfan Sul-
tan, Dr Aya Alali, and Dr Mohammad Al Eysayi for
their efforts during the conduct of this study. The au-
thors also thank Dr Ward Shan, Dr Adnan Amawi,
American Journal of Orthodontics and Dentofacial Orthopedics
89
Dr Bader Brogan, and Mr. Forsan Otoum for their help
and service during the conduct of this research.
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