CASE REPORT
Transposition of a maxillary canine and a lateral
incisor and use of cone-beam computed
tomography for treatment planning
Jason Pair
Valencia, Calif
This report describes the orthodontic treatment of a 12-year-old girl with transposition of the maxillary left canine
and the lateral incisor. Cone-beam computed tomography was used during treatment planning. The transposed
tooth positions were corrected with an unconventional orthodontic approach. Treatment alternatives and their
clinical concerns are presented. (Am J Orthod Dentofacial Orthop 2011;139:834-44)
T
ransposition is defined as an unusual type of ec-
topic eruption where a permanent tooth develops
in the position normally occupied by another per-
manent tooth.1 It is a rare occurrence that affects less
than 1% of the population.2-5 Transposition affects the
maxillary dentition (68.5%-76%) more frequently than
the mandibular dentition.6-8 The most common type of
transposition (55%-70%) is that of the maxillary canine
and the first premolar (Mx.C.P1).4,6,9 Twenty-seven per-
cent of Mx.C.P1 patients demonstrate bilateral occur-
rence.8 Maxillary canine-lateral incisor transposition
(Mx.C.I2) is the second most common type at 20% to
42%, with only 5% having bilateral occurrence.8,9
Peck et al10 described Mx.C.P1 as an anomaly “result-
ing from genetic influences within a multifactorial inher-
itance model.” This was based on an elevated frequency
of associated dental anomalies, elevated bilateral occur-
rence (27%), familial occurrence (11%), and differences
between male and female prevalence (females 1.55:1
males).10,11 Others have demonstrated elevated
frequencies of associated dental anomalies with
Mx.C.P1 patients.6,9,11-13 These associated dental
anomalies included hypodontia, submerged deciduous
teeth, retained deciduous teeth, and supernumerary teeth.
Unlike Mx.C.P1, it has been hypothesized that the
etiology of Mx.C.I2 is more environmental than genetic.
Private practice, Valencia and Northridge, Calif; volunteer faculty, Orthodontic
Residency Program, University of California at Los Angeles.
The author reports no commercial, proprietary, or finanical interest in the prod-
ucts or companies described in this article.
Reprint requests to: Jason Pair, 23838 Valencia Blvd, Suite 42, Valencia, CA
91355; e-mail, jpair@hotmail.com.
Submitted, July 2009; revised and accepted, August 2009.
0889-5406/$36.00
Copyright ! 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.08.035
834
Dentofacial trauma in the deciduous dentition, with
subsequent drifting of the developing permanent teeth
is the most common etiologic factor.2,8 There are few
reports of familial occurrence or dental anomalies
associated with Mx.C.I2 transpositions.14 The only den-
tal anomaly that has an apparent association with
Mx.C.I2 is increased third molar agenesis.15
Treatment of Mx.C.I2 depends on many factors. If
the central incisor has significant root resorption (ei-
ther from past dentofacial trauma or due to the ectop-
ically erupting canine), the central incisor can be
extracted and the canine moved into its position, as
has been reported.16 Significant restorative work is
necessary for acceptable smile esthetics with this treat-
ment plan.
If extractions are indicated because of severe crowd-
ing or a desire for a change in the soft-tissue profile, then
the following extraction pattern should be considered:
the transposed canine and the 3 first premolars in the re-
maining quadrants. If this option is chosen, it could be
necessary to intrude the first premolar next to the lateral
incisor so that the height of the gingival margin matches
that of the contralateral canine. The premolar crown
could then be veneered and brought into occlusal func-
tion. It also might be necessary to extract the transposed
lateral incisor (rather than the canine) if it has already
demonstrated root resorption. Extraction of transposed
peg-shaped lateral incisors and substitution of canines
has also been described.14
Another possibility—leaving the canine and the lateral
incisor transposed—is rarely a good esthetic or functional
option. The difficulty of resolving the transposition is the
risk of root interference as the canine passes distally
around the lateral incisor. This interference could lead
to significant root resorption and subsequent pathologic
Pair
tooth mobility of the affected teeth. However, resolving
the transposition is ideal for esthetics and function.
DIAGNOSIS AND ETIOLOGY
A girl, aged 12 years 5 months, came to my practice
with the chief complaint of malaligned teeth (Figs 1
and 2). She was physically healthy with no history of
dental trauma. She had a slightly convex profile with
mild chin asymmetry to the right. She had a pleasing
smile and lip competence. The intraoral examination
showed half-cusp Class II molar relationships with
crowding of 3.5 mm in the mandibular arch and 9 mm
in the maxillary arch. The maxillary left canine was
blocked out of the arch, and the maxillary left lateral in-
cisor was proclined labially. The maxillary left canine
could not be palpated labially or palatally. Her maxillary
dental midline was displaced 2 mm to the left of the fa-
cial midline and mandibular dental midline. Overbite
was 25% with an exaggerated curve of Spee of 3 mm.
The panoramic radiograph showed normal root and
tooth development, with the exception of transposition
of the maxillary left canine and the lateral incisor (Fig 3).
Cephalometric assessment showed a Class I, mesofacial
skeletal pattern (Wits, 1.5 mm; ANB, 2.5! ; SN-GoGn,
33! ) with normally inclined incisors (Fig 4, Table).
TREATMENT OBJECTIVES
Ideally, the treatment objectives would include full
resolution of the transposition. However, achievement
of this objective might subject the transposed teeth to
mechanics that have significant root resorption risks.
Class I molar and canine relationships, ideal overjet
and overbite, and an esthetic smile with minimal change
in the profile were desired.
TREATMENT ALTERNATIVES
The following treatment alternatives were considered
and discussed with the patient and her parents.
1. Extraction of 3 first premolars (14, 34, 44) and the
transposed canine (23) with intrusion of the maxil-
lary left first premolar (24) to match the gingival
height of the contralateral canine. After orthodontic
treatment, a veneer would be placed on tooth 24 to
match the morphology of the contralateral canine
and bring it into occlusion for canine disclusion. Ex-
tractions without careful anchorage control could
negatively affect her profile.
2. Nonextraction treatment without resolution of the
transposition followed by postorthodontic veneers
in an attempt to normalize crown morphology and
create ideal function. The disadvantage is the un-
American Journal of Orthodontics and Dentofacial Orthopedics
835
likelihood of ideal smile esthetics. The advantage
is the minimal risk of root interferences during
alignment. There is also less chance of bony loss
of the buccal cortical plate of the canine, since it
does not have to pass labially to the lateral incisor.
3. Extraction of the maxillary left lateral incisor (22),
normalization of the canine, and a future implant
in the lateral position. This would be considered if,
when analyzing the initial records, significant root
resorption was found on the lateral incisor. The ad-
vantage is a relatively short treatment time. How-
ever, the future cost of an implant-supported
crown must be considered.
4. Nonextraction treatment with full resolution of the
transposition. This plan has been described previously
in the literature.1,2,17 One disadvantage of resolving
a transposition is the likelihood of a protracted
treatment time, as has been demonstrated
previously.1,2,17,18 Another disadvantage is the
likelihood of root resorption to the lateral incisor if
root interferences are not eliminated during
mechanics. Also, there is the potential for loss of the
buccal cortical plate on the canine as it passes
distally and labially to the lateral incisor. It was
explained to the patient’s family that, if the lateral
incisor suffered significant root resorption, it would
be extracted, the canine would be normalized, and
a future implant-supported crown would be placed
in the lateral incisor’s position (alternative 3).
All treatment options would achieve an ideal Class I
molar relationship and ideal overjet. However, the pa-
tient and her parents wished to avoid postorthodontic
restorative work if possible and were willing to accept
a protracted treatment plan (alternative 4). The risks of
root resorption to the lateral incisor and loss of the buc-
cal bony plate on the canine were understood and
accepted by the patient.
TREATMENT PROGRESS
The exact relative positions of the transposed teeth
were impossible to ascertain on the pretreatment pano-
ramic radiograph. We instead planned on initially level-
ing the maxillary arch (with no bracket on 22, except for
a metal pad to satisfy the patient, who was self-
conscious about having a front tooth without a bracket
attached). After leveling, we planned to open space for
the transposed teeth, followed by more radiographs
and, possibly, a cone-beam computed tomography
(CBCT) scan to better assess the position of the canine
relative to the root of the lateral incisor.
Fixed appliances (self-ligating Damon2, 0.022-in
slot; Ormco Corporation, Orange, Calif) were placed in
June 2011 " Vol 139 " Issue 6
836
Fig 1. Pretreatment photographs.
the maxillary arch in May 2005. A nickel-titanium (NiTi)
open coil was used to gain more space for the trans-
posed teeth. Radiographs taken after the arch was lev-
eled did not clearly show the relative tooth positions
(Fig 5); an occlusal image suggested that the canine
crown was palatal to the root of the lateral incisor,
but the periapical images suggested that the crown of
the canine was buccal to the lateral incisor root.19 A
CBCT scan was obtained in December 2005 (Fig 6). The
scan and the composite video showed a complete trans-
position, with the crown of the canine buccal to the root
of the lateral incisor, yet palatal to the crown of the lateral
incisor (still images, Fig 6). Bracket placement and arch-
wire engagement at this time on the lateral incisor would
bring the root labially and into the crown of the canine,
most likely leading to root resorption. Surgically expos-
ing the canine and pulling it distally would drag the
crown of the canine across the cervical junction of the
lateral incisor, also a risky proposition. It appeared in-
stead that, if the lateral incisor could be simply tipped
palatally, it would create enough space to bring the ca-
nine into the arch without engaging the lateral incisor
June 2011 " Vol 139 " Issue 6
Pair
on its way down. A palatal bar was fabricated with sol-
dered hooks; the bar and buttons were placed on the
crown of the lateral incisor. The lateral incisor was acti-
vated with a power chain (Fig 7). After 6 weeks, a second
CBCT scan was taken. It showed complete separation of
the lateral incisor root and the canine crown (still images,
Fig 8). A path had been cleared for surgical exposure and
traction of the canine. No root resorption was noted on
the lateral incisor.
The canine was brought into the arch with a light
0.014-in NiTi wire (in the bracket slots), while the arch
form was stabilized with a stainless steel overlay arch
(0.016 3 0.025 in) (Fig 9). The overlay arch was ligated
over the closed doors of the self-ligating brackets. This
mechanical setup allows for minimal friction acting on
the leveling arch as it pulls the canine down, while the
integrity of the arch is maintained with the stainless steel
archwire. The manner in which the overlay wire is ligated
to the brackets (over the wings) does not allow the liga-
tion wires to interfere with the slots of the bracket, so the
0.014-in NiTi wire can slide through with minimal fric-
tion. After the canine was brought into the arch, the
American Journal of Orthodontics and Dentofacial Orthopedics
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Fig 2. Pretreatment dental casts.

Fig 4. Pretreatment cephalometric tracing showed

a Class I mesofacial skeletal pattern (Wits, 1.5! ; ANB,
2.5! ; SN-GoGn, 33! ) with normally inclined incisors.
Fig 3. Pretreatment radiographs showed normal root and
tooth development with the exception of the transposition
of the maxillary left canine and the lateral incisor.

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838 Pair

Table. Cephalometric analysis

Pretreatment Posttreatment
SNA 75! 76!
SNB 72.5! 75!
ANB 2.5! 1!
Wits #1.5 mm #3 mm
SN Go-Gn 31.5! 37!
FMA 29.5! 28!
Max 1-NA 4 mm 8 mm
Max 1-SN 93.5! 105!
Mand 1-NB 5 mm 7 mm
Mand 1-Go-Gn 91! 96!
E-line 0 mm #1 mm

lateral incisor was released from traction, and the canine

was distalized into its normal position. The lateral incisor
was teased back into the arch form with elastic thread. A
localized gingivectomy was performed on the lateral in-
cisor to remove the excessive labial gingiva before
a bracket was placed, and the tooth was engaged with
the archwire. The bracket used on the lateral incisor
was placed upside down (#8! ) to affect labial root tor-
que. Class II elastics, anterior box elastics (both 0.25-in,
4 oz), and interproximal reduction of the mandibular
incisors were used to idealize the occlusion. The final 8
months of treatment were used to effect as much labial
root torque on tooth 22 as possible to match the inclina-
tion of the contralateral lateral incisor.
After 43 months of treatment, the appliances were
removed, the final records were taken, and a fixed lin-
gual retainer was placed canine-to-canine in the man-
dibular arch (Figs 10-13). An Essix-type retainer for
daytime use and a Hawley retainer for nighttime use
were given for retention of the maxillary arch.
TREATMENT RESULTS
The transposition was fully resolved, and ideal Class I
molar and canine relationships were achieved. Ideal
overjet and overbite were achieved with adequate canine
disclusion and protrusive guidance.
Cephalometric analysis showed that a Class III growth
pattern had occurred during the treatment, with signif-
icant mandibular growth (both vertically and
horizontally) and no maxillary change (Figs 13 and 14,
Table). Cast and cephalometric analysis showed that
the crowding was resolved in 2 ways: through lateral
arch expansion and proclination of the incisors. The
mandibular molars expanded by 4 mm, the mandibular
first premolars expanded by 4 mm, the maxillary first
molars expanded by 6 mm, and the maxillary first
premolars expanded by 8 mm. However, the
mandibular canines showed no expansion, considered
important for long-term stability. The mandibular
Fig 5. Radiographs after leveling the occlusal arch.
incisors proclined 5! to 96! , but stayed within a standard
deviation from a normal value of 92! . The maxillary in-
cisors, however, changed inclination by 112.5! . The
composite tracing demonstrates that the changes in
maxillary inclination were both labial crown tipping
and palatal root torque. It makes sense that the maxillary
incisors had to be proclined labially to maintain a positive
overjet as the mandible grew at a faster pace than the
maxilla.
The composite tracings show no negative change in
her soft-tissue profile with some straightening of the
profile as her mandible grew forward. This was a goal
of both the parents and the clinician.
The gingival margins of the maxillary anterior teeth
were not ideal but could be idealized with a minimally
invasive gingivectomy procedure. There also appeared
to be mild canting of the occlusal plane in the final re-
sult, not uncommon in patients with unilateral canine
impactions. Despite the effort and subsequent success
to upright the maxillary left lateral incisor with labial
root torque, the maxillary first premolars were finished
with too much buccal crown tip.
The final panoramic radiograph demonstrates ideal
root alignment except for the maxillary left lateral inci-
sor, which was angulated distally (Fig 12). Because of
a discrepancy between the long axes of the root and
the crown, the clinical crown appears well aligned in
her smile. About 2.5 mm of root resorption was noted
on the tip of the maxillary left lateral incisor (18%). No
root resorption was noted on the CBCT scan after the
crown of this tooth was tipped back into the palate.
The root resorption most likely occurred as heavy labial

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Fig 6. The CBCT scan showed a complete transposition, with the crown of the canine positioned
buccally to the root of the lateral incisor but palatally to the crown of the lateral incisor.
Fig 7. A palatal bar with soldered hooks and buttons was placed on the crown of the lateral incisor and
activated with a power chain.
root torque was being expressed during the last 8
months of treatment.
After 9 months, the patient returned, and the reten-
tion photos were taken, demonstrating good stability of
the final result (Fig 15).
DISCUSSION
This patient presented with a challenging case of uni-
lateral transposition of the left lateral incisor and canine.
The transposition was complete, with both the crown
and the root of the canine mesial to the crown and the
root of the lateral incisor. The case was further compli-
cated because the canine was unerupted, and conven-
tional radiographs offered conflicting evidence of its
relative position to the lateral incisor. Other reported
cases of Mx.C.I2 transposition had initial presentations
with the canine fully erupted labially in the arch
form.1,2 Orthodontic mechanics are certainly easier to
conceive when all affected teeth can be absolutely
localized.
Complete transpositions require complex and often
protracted treatment plans with no guarantee of success.
Parker20 suggested that heroic efforts to resolve transpo-
sitions can be disappointing. Therefore, careful consid-
eration must be given to the specific circumstances
of the patient, including predicted compliance and
American Journal of Orthodontics and Dentofacial Orthopedics
839
tolerance of protracted treatment, before embarking
on a heroic treatment plan.
The ultimate success of the treatment plan hinged on
accurate assessment of the relative positions of the
transposed teeth. Conventional radiography in this
case gave conflicting viewpoints. Ericson and Kurol21 re-
ported that, in a sample of Swedish children, assessment
using conventional periapical radiography was only 80%
successful in the localization of ectopic canines. The
other 20% required tomography for accurate localiza-
tion. The conventional periapical assessments were least
successful in patients whose canine overlapped the
lateral incisor (similar to this case report).
There have been reports of successful use of comput-
erized tomography (CT) in the localization of impacted
canines.22 Although useful for elucidating the exact lo-
cation of the impacted tooth, the cost to the patient is
often prohibitive. The amount of radiation exposure is
also an argument against the routine use of medical
CT scans for localization of impacted teeth. However,
the value of CT scans was evident in these reports. Eric-
son and Kurol21 reported that CT can detect 50% more
cases of resorption than periapical and panoramic radi-
ography. They also stated that, when clinicians were
given the additional information from a CT scan, they
changed their treatment plan 43% of the time.
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Fig 8. A second CBCT scan showed complete separation of the lateral incisor root and the canine
crown. A path had been cleared for surgical exposure and traction of the canine. No root resorption
was noted on the lateral incisor.

Fig 9. A, The canine was brought into the arch with light 0.014-in NiTi wire; B, the arch form was sta-
bilized with a stainless steel overlay arch (0.016 3 0.025 in); C, the lateral incisor was teased back into
the arch form with elastic thread; D, a localized gingivectomy was performed on the lateral incisor to
remove the excessive labial gingiva, and a bracket was then placed and the tooth engaged with the
archwire.

Today, we have the ability to gather undistorted, ac-
curate 3-dimensional views of the jaws with CBCT at
a cost that is not prohibitive and at a radiation dose
that is considerably less than that of conventional med-
ical CT. The problem with panoramic images is that they
are magnified and distorted. Distortion is the unequal
magnification of different parts of the same image. Pan-
oramic distortion makes it unreliable for making mea-
surements.23 Panoramic and periapical radiography
provide only 2-dimensional images, whereas CBCT can
provide buccolingual, axial, coronal, sagittal, and pano-
ramic views. And, with the use of software, these images
can be easily converted into accurate 3-dimensional
images and videos.
Panoramic and periapical films in this case report
could not provide an accurate assessment of the relative
positions of the transposed teeth. They also could not
provide an accurate assessment of whether the lateral
incisor suffered any root resorption as the canine erup-
ted ectopically. Ericson and Kurol24 reported that CT
scanning substantially increased the detection of root
resorption on incisors adjacent to ectopically erupting
maxillary canines. The sensitivity of intraoral (periapi-
cal) films was low when diagnosing the resorptions.

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Fig 10. Posttreatement photographs.
Any signs of pretreatment root resorption (especially
midroot and into the pulp canal) would have swayed
my treatment plan to extraction of the affected lateral
incisor and an eventual implant-supported crown
restoration.
The necessity of moving the lateral incisor palatally
has been discussed before.2,13 Doing so in this patient
avoided potential root interferences and prevented
potential loss of the cortical plate by allowing the
canine to erupt into the arch rather than too far
labially. The second CBCT scan confirmed the root
separation, so that the treatment plan could proceed
with confidence.
Once space was gained for the lateral incisor, it was
necessary to bring it into the arch form. Effecting signif-
icant labial root torque through archwire manipulation
and bracket placement (upside down to effect #8! of tor-
que) was the thrust of the final 8 months of treatment.
The final result demonstrated mild root resorption
(2.5 mm, 18%) on the maxillary left lateral incisor that
should have no long-term consequences with regard
to loss of tooth vitality or tooth mobility. Kokich25
American Journal of Orthodontics and Dentofacial Orthopedics
841
defined moderate to severe root resorption as greater
than a 20% reduction in the original root length.
Several authors have looked at the long-term conse-
quences of orthodontically induced apical root resorp-
tion. Some evidence suggests that orthodontically
induced root resorption does not progress once the ap-
pliances are removed.26,27 Falahat et al28 demonstrated
a favorable long-term prognosis in a long-term fol-
low-up (2-10 years) of resorbed maxillary incisors. Of
32 teeth in the study, 13 had repair of the resorption la-
cunae, 12 remained unchanged, and 7 had increased
root resorption. However, of the 7 incisors with increased
resorption, none lost vitality or exhibited ankylosis.
Jonsson et al29 demonstrated that postorthodontic
root resorption remained stable up to 25 years after
treatment, if the roots were at least 10 mm in length
and had a healthy periodontium.
Despite the difficulty of planning the treatment for
this patient, the protracted treatment time, and the
additional costs of imaging, the final result was grat-
ifying for the clinician, the patient, and the patient’s
family.
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Fig 11. Posttreatement dental casts.

Fig 13. Posttreatment cephalometric tracing.

CONCLUSIONS
Complete resolution of a transposed lateral incisor
and a canine is a unique challenge for an orthodontist.
Fig 12. Posttreatment radiographs. Careful consideration of the relative positions of the

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Fig 14. Cephalometric analysis showed that a Class III growth pattern had occurred during the treat-
ment, with significant mandibular growth (both vertically and horizontally) and no maxillary change.

Fig 15. Nine months postretention.

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844
transposed teeth is imperative for developing a plan that
will minimize the likelihood of negative treatment
consequences (root resorption with subsequent tooth
mobility and periodontal issues). This case report dem-
onstrates the difficulty of using conventional radiogra-
phy to adequately assess the relative positions of
transposed teeth. CBCT imaging was necessary to confi-
dently execute a successful treatment plan that resulted
in an esthetic and functional outcome.
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