Journal of Investigative and Clinical Dentistry (2012), 3, 1–5

ORIGINAL ARTICLE
Oral Radiology

Diagnosis and localization of impacted maxillary canines:

comparison of methods
Anand K. Sajnani1 & Nigel M. King2
1 Bin Muftah Medical Centre, Doha, Qatar
2 School of Dentistry, University of Western Australia, Nedlands, Perth, Australia

Keywords
diagnosis, horizontal parallax, impacted
maxillary canines, localization of canines,
vertical parallax.
Correspondence
Dr Anand K. Sajnani, Bin Muftah Medical
Centre, Al Markhiya Street, PO Box: 201357,
Doha, Qatar.
Tel: +974-30181952
Email: aksajnani@gmail.com
Received 6 March 2012; accepted 9 June
2012.
doi: 10.1111/j.2041-1626.2012.00163.x
Abstract
Objectives: Numerous clinical signs may be indicative of a canine impaction;
however, studies determining the efficiency of visual inspection and digital pal-
pation in localizing an impacted maxillary canine are sparse. Of the radio-
graphic techniques, no studies have compared the accuracy of the horizontal
and the vertical parallax techniques to determine the location of an impacted
canine. Hence, the objectives of this study were to evaluate the efficiency of
visual inspection and digital palpation, and to compare the accuracy of the
horizontal and vertical parallax techniques in determining the location of an
impacted maxillary canine.
Methods: The study sample comprised the records of 522 patients who had
attended a dental hospital. The location of an impacted maxillary canine was
determined radiographically using the vertical and the horizontal parallax prin-
ciples. The findings were then confirmed from the surgical records in those
cases that had undergone surgical intervention of the impacted canine.
Results: The position of the impacted canine was determined successfully by
visual inspection and digital palpation in 85.3 and 85.2% of the cases respec-
tively.
Conclusions: The vertical parallax technique demonstrated a higher degree of
accuracy (97.7%) and a greater degree of diagnostic capability (98.2%) when
compared with the horizontal parallax technique (92.6 and 78.0% respectively).

palpation, and radiography. Numerous clinical signs may

Introduction
It has been stated that “The upper cuspids are the freak
teeth of the anterior portion of the mouth, just as the
lower third molars are the freak teeth of the mandible.”1
When dealing with these “freak” teeth, an accurate diag-
nosis is critical for the success of the proposed treatment.
A correct diagnosis in the treatment of any disease is
more than half the success of the case, whereas a faulty
diagnosis is usually responsible for much suffering on the
patient’s part and dissatisfaction on the part of the clini-
cian.1 It is therefore essential to accurately diagnose and
localize impacted maxillary canines.
There are basically three methods used for the localiza-
tion of an impacted maxillary canine; visual inspection,
be indicative of a canine impaction, such as the lack of a
“canine bulge” in the buccal sulcus at the age of 10 years,
prolonged retention of a primary canine,2 delayed erup-
tion of the permanent canine, asymmetry in the exfolia-
tion of primary canines and eruption of the right and left
permanent canines,3 loss of vitality and increased mobility
of a permanent incisor.4 However, studies determining
the efficiency of the clinical evaluation (visual inspection
and digital palpation) for the localization of an impacted
maxillary canine are sparse.5
For approximately 30% of cases radiography is the only
means of determining the position of an impacted
canine.6 Accurate localization in three planes of space
normally requires the use of more than one film.7 Precise

ª 2012 Blackwell Publishing Asia Pty Ltd 1

Method comparison for impacted canines A.K. Sajnani and N.M. King

localization is crucial for the determination of the extent

of any root resorption of the adjacent incisors, predicting
the direction of subsequent orthodontic forces and plan-
ning the means of surgical access to the impacted canine.8
Currently, there are five accurate radiographic methods
that can be used to localize an impacted canine: horizon-
tal tube shift, vertical tube shift, right angle technique,
stereoscopy, and computed tomography. Of these, the
horizontal tube shift9 and the vertical tube shift10 are of
special interest because they utilize radiographs that are
most commonly taken during a routine initial assess-
ment.11 The horizontal tube shift utilizes two periapical Figure 2. Panoramic radiograph of a 15-year-old female patient
radiographs, or two occlusal radiographs, whereas the ver- demonstrating bilaterally impacted maxillary canines.
tical tube shift utilizes a panoramic radiograph along with
an occlusal radiograph. Both techniques utilize the paral-
lax principle, which in radiological terms can be described
as the apparent displacement of the image of the object
to be localized, relative to the image of a reference
object.12 This is caused by changing the angulation of the
X-ray beam, by altering the angulation of the X-ray tube
in a horizontal plane for the horizontal tube shift tech-
nique (Figure 1), and in a vertical plane for the vertical
tube shift technique (Figures 2 and 3). However, only one
study could be identified in the scientific literature that
compared the accuracy of the horizontal tube shift with
the vertical tube shift to determine the location of an
impacted maxillary canine.13 Hence, the objectives of this
study were to evaluate the efficiency of visual inspection
and digital palpation, and to compare the accuracy of the
horizontal tube shift and the vertical tube shift in deter-
mining the location of an impacted maxillary canine.
Figure 3. Maxillary occlusal radiograph of the same patient in Fig-
Materials and methods ure 2. Visualizing both the figures (panoramic radiograph and maxil-
lary occlusal radiograph) it can be ascertained that both the impacted
The study sample was gathered from the records of patients maxillary canines are palatally placed.
who had attended the Paediatric Dentistry and Orthodon-
tic clinics at the Prince Philip Dental Hospital, Hong Kong SAR, for comprehensive treatment for impacted maxillary
canines. Patients with any form of orofacial cleft or medical
condition such as metabolic or endocrine disorders were
excluded from the study. The sample comprised 522
patients with ages at the time of diagnosis that ranged from
9 years to 25 years. The description of the impacted canine
was obtained from the case notes, and all radiographs used
to determine the location of an impacted maxillary canine
were retrieved. Radiographs were examined in a darkened
room by a single examiner (AKS) using an illuminated
X-ray viewing box. The location of impacted maxillary
canines as determined using the radiographs employing the
vertical tube shift principle and the horizontal tube shift
principles were recorded. The data obtained using these
Figure 1. Two periapical radiographs of the same patient taken at records and radiographs were then confirmed from the sur-
different horizontal angulations demonstrating that the impacted gical observations recorded in the case notes following
maxillary canine is buccally located. a surgical intervention as a part of the comprehensive

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A.K. Sajnani and N.M. King
treatment plan. Any radiographic image that demonstrated
blurring, distortion, or other image anomalies were
excluded from the study, thus providing the final sample
size for both the radiographic techniques (n). The diagnos-
tic capability and accuracy of each of the techniques was
then determined. The diagnostic capability (a) was defined
as the ability of the technique (the panoramic and maxillary
occlusal radiograph in the case of vertical parallax and two
periapical radiographs in the case of horizontal parallax) to
demonstrate discernable movement so that the location of
the impacted canine was determined. The percentage diag-
nostic capability was expressed as (a 9 100)/n. This find-
ing was then compared with the case notes, which had
recorded the position of the impacted canine at the time of
the surgery (b). The confirmation from surgical findings
was expressed in percent as (b 9 100)/a. Any discrepancy
in the position of the impacted canine as recorded from the
radiograph when compared with the actual position deter-
mined at the time of surgery was recorded as false diagnosis
(c) and was also calculated in percent as (c 9 100)/a. The
degree of accuracy (d) of the technique was then calculated
as a percentage using the formula d = (100 c).
Results
Impaction of the canine was easily diagnosed and the
position determined by visual inspection in 122 of the
total patients. In 104 of them, the diagnosis was found to
be correct, thus establishing a success rate of 85.3%. Like-
wise, the impacted canine could be diagnosed and the
position of the tooth determined by palpation in 196
patients; the diagnosis was correct in 167 (85.2%) of the
cases. Thus, in approximately 15% of the patients visual
inspection and digital palpation failed to detect the cor-
rect location of the impacted canine.
A panoramic radiograph was used for diagnosis of an
impacted canine in all 522 patients. Maxillary anterior
occlusal films were used in 444 patients to more accu-
rately determine the position of the impacted canine
using the vertical parallax principle. Two periapical
films, taken at different horizontal angles and thereby
employing the horizontal parallax principle, were used
in 173 patients. The vertical parallax technique demon-
strated a higher degree of accuracy (97.7%) in determin-
ing the position of the impacted canine than the
horizontal parallax technique (92.6%). Moreover, the
Table 1. Degree of accuracy of the vertical parallax and horizontal parallax techniques
Type of Sample Radiographic
parallax size (n) diagnosis (a)
Vertical 444 436 (98.2%)
Horizontal 173 135 (78.0%)
ª 2012 Blackwell Publishing Asia Pty Ltd
Method comparison for impacted canines
vertical parallax technique also demonstrated a higher
degree of diagnostic capability (98.2%) when compared
with the horizontal parallax technique (78.0%). Thus,
the vertical parallax technique demonstrated a greater
ability to determine the position of the impacted canine
to a higher degree of accuracy than the horizontal paral-
lax technique (Table 1).
Discussion
Visual inspection and digital palpation are the initial
methods used to establish that a canine is impacted and
to commence to localize the tooth. Impaction of the max-
illary canine frequently can be diagnosed easily and the
position can be determined accurately in many cases
using these methods. In one study 70% of the impacted
teeth could be palpated.6 However, occasionally the bony
canine eminence has been confused with the presence of
the tooth and the fact that a canine has been impacted
has been missed.12 This may be the reason why visual
inspection and digital palpation failed to detect the cor-
rect location of the impacted canine in approximately
15% of patients. Nevertheless, as demonstrated by this
study, a careful clinical examination may reveal valuable
information about an impacted canine even before any
radiographs are taken.
The fact that so many radiographic techniques exist to
localize an impacted maxillary canine suggests that no
single one is ideal.11 Panoramic radiographs serve as veri-
fication for clinically suspected ectopic position of maxil-
lary canines and allow for identification of any
impactions. Thus, an additional occlusal radiograph used
in conjunction with a panoramic radiograph to localize
an impacted maxillary canine can prove to be the best
combination.12
As far as could be ascertained, only one study could be
identified in the literature that compared the diagnostic
capabilities and accuracy of the radiographs utilizing the
vertical tube shift technique described by Keur10 and radio-
graphs utilizing the horizontal tube shift employing the
principle reported by Clark.9 Moreover, in their study
Armstrong and co-workers13 utilized an anterior occlusal
radiograph and a periapical radiograph for assessing the
diagnostic accuracy of the horizontal parallax technique.
The anterior occlusal films used in their study had been
recorded using the same tube position and angulation as a
Confirmation from Degree of
surgical findings (b) False diagnosis (c) accuracy (%) (d)
313 (71.8%) 10 (2.3%) 97.7
81 (60.0%) 10 (7.4%) 92.6
3
Method comparison for impacted canines
periapical view of a central incisor.13 They found that local-
ization of ectopic maxillary canines was significantly more
successful with the horizontal parallax technique than with
the vertical parallax technique. It has been suggested also
that a vertical tube shift is not as easy to interpret as the
horizontal tube shift because it is more difficult to identify
suitable reference points to ascertain in which direction the
crown of the impacted maxillary canine has apparently
moved.12,13 On periapical films using the horizontal tube
shift the lines created by the periodontal ligament and pulp
chamber serve as good reference points.
However, this study found that the vertical parallax
technique not only had a higher capability of diagnosing
an impacted maxillary canine but also demonstrated a
greater degree of accuracy. Moreover, the accuracy of the
radiographic observations was confirmed from the surgi-
cal findings, which provided a definitive location of the
impacted teeth. The vertical parallax technique was thus
found to be more accurate than the horizontal parallax
technique. The possible reason for this greater accuracy
could be the greater relative movement of the tooth in
the two radiographs, which had been taken at different
vertical angles (panoramic radiograph and occlusal radio-
graph), making it easier to ascertain the position. Also, it
has been suggested that occlusal radiographs used in illus-
trations of horizontal tube shift are superior to periapical
radiographs taken for the same purpose because they
cover a larger surface area.12 However, in this study all
the radiographs that were used to demonstrate the hori-
zontal parallax technique were periapical radiographs.
Currently, cone beam computed tomography (CBCT)
has been gaining appreciable popularity amongst clini-
cians as it provides the third dimension to the clinical
diagnosis and treatment plan. Although CBCT in princi-
ple has been in use for more than 20 years, only recently
have affordable systems become commercially available.14
Walker and co-workers (2005) in their radiographic study
involving 27 impacted maxillary canines demonstrated
that CBCT provides important features for the impacted
tooth including size of the follicle, inclination of the long
axis of the tooth, relative buccal and palatal positions,
amount of bone covering the tooth, resorption of adja-
cent teeth, local anatomic considerations, and overall
stage of dental development, which are advantageous in
the management of this conditon.15 Likewise, when com-
paring the traditional two dimensional (2D) images to
the three dimensional (3D) CBCT images in patients with
impacted upper cuspids. Dent Cosmos
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4 ª 2012 Blackwell Publishing Asia Pty Ltd
A.K. Sajnani and N.M. King
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