January 2008 Orthodontic Update 7

Grant T McIntyre

Managing the Maxillary

Canine: 1. Diagnosis,
Localization and
Interceptive Treatment
Abstract: Unerupted permanent maxillary canines include normally erupting canines, those that are ectopic and canines that are
impacted. The identification of permanent maxillary canines that are developing ectopically in the mid-late mixed dentition ensures that
corrective treatment, usually involving extraction of the deciduous canines, is instituted promptly. The first part of this article discusses the
normal eruption pathway, methods of localizing the permanent maxillary canine, when to suspect ectopy, monitoring developmentally
normal canines and how to normalize the aberrant eruption pathway by extracting the deciduous canines and/or creating space in the
buccal segments.
Clinical Relevance: The identification of ectopic and impacted permanent maxillary canine teeth allows appropriate treatment to be
instituted. In many cases of ectopic permanent maxillary canines, interceptive treatment can prevent later impaction.
Ortho Update 2008; 1: 7–15

U
nerupted permanent maxillary
canines include those that are
normally positioned, as well as
ectopic and impacted canines. (‘Ectopy’
is defined as ‘abnormal position’ whilst
‘impacted’ involves further development
being obstructed by hard and soft tissue
structures.) The most severe form of
ectopy is transposition. This is positional
interchange of the canine with another
tooth.1 In Caucasian populations, the
prevalence of ectopic and impacted
maxillary canines has been estimated
to be between 0.92–2.2%, with 85% of
these ectopic teeth being palatal to the
line of the arch, whilst 15% are located
buccally.2,3 Interestingly, in Oriental and
Asian populations, the majority of canine
impactions are found buccally, with
relatively few being palatal to the line of the
arch.4,5
Problems with impacted
permanent canine teeth
Impacted permanent maxillary
canines are associated with several
aesthetic, functional and orthodontic
problems. These include:
n Absence of maxillary dento-alveolar
symmetry (where the condition is
unilateral);
n Limited deciduous canine prognosis
often with poor aesthetics;
n Absence of canine protected occlusion;
n Resorption of adjacent permanent
incisors or premolars (Figures 1 and 2);
n Internal or external resorption of the
impacted canine;
n Cyst formation around the unerupted
canine;
n Obstruction to movement of nearby
teeth;
n Unwanted movement of adjacent teeth
with possible loss of arch length;
n Flattened nasolabial fold due to the
absence of the canine eminence;
n Referred pain.
Permanent incisor root
resorption
The most significant sequela
of an impacted permanent canine tooth

Grant T McIntyre, BDS, FDS RCPS(Glasg), MOrth RCS(Edin), PhD, FDS(Orth) RCPS(Glasg), Consultant Orthodontist, Dundee Dental Hospital
and School, 2 Park Place, Dundee, DD1 4HR.
8 Orthodontic Update
a
a
Figure 1. Lateral incisor root resorption caused
by an impacted permanent maxillary canine: (a)
clinical appearance; (b) radiographic extent of
resorption).
is resorption of the adjacent permanent
incisor roots (Figure 1). When investigated
using intra-oral and panoramic radiographs,
12% of children aged 10–13 years with
ectopic permanent maxillary canines
are likely to demonstrate a degree of
permanent incisor root resorption.6 Intra-
oral and panoramic radiographs are, of
course, two-dimensional images, and fail to
demonstrate resorption occurring on the
palatal and buccal root surfaces until it is
extensive. Moreover, maxillary permanent
incisor root resorption, resulting from
an ectopic canine, usually occurs in the
mid-root region and is symptomless.6 It
is therefore worrying to note that, when
conventional and cone-beam computed
tomography scanning have been used to
investigate ectopic permanent maxillary
canines three-dimensionally, up to 67%
have been shown to be associated with
permanent incisor root resorption.7,8
Notably, impacted permanent
maxillary canines most likely to be
Figure 2. First premolar root resorption caused by
an ectopic permanent maxillary canine: (a) DPT
view (note the unrestored caries in 6/, /6 and /6 7
and the presence of four developing third molars);
(b) periapical view.
Figure 3. Permanent maxillary canines developing between the permanent maxillary lateral incisor and
first premolar roots in the infra-orbital region.
associated with permanent incisor root
resorption occur in patients below age
14, where the canine cusp is medial to the
lateral incisor midline on periapical and
panoral radiographs. This risk of resorption
is greatest with mesial and horizontal
canines.9
Why do canines develop
ectopically?
The permanent maxillary canine
is genetically programmed to develop
between the permanent lateral incisor
and the first premolar teeth in the region
January 2008
of the infra-orbital foramen (Figure 3)
by homeobox genes. Genetic control of
the subsequent long path of eruption10,11
is modified by a number of local ‘risk’
factors12 producing several opportunities
for permanent maxillary canines to become
ectopic. The distal surface of the permanent
lateral incisor root guides the developing
permanent canine into the line of the
arch. Diminutive peg-shaped permanent
lateral incisors and developmentally
absent permanent lateral incisors have
been associated with a greater incidence
of palatal canine impaction12,13 (Figure 4). It
January 2008 Orthodontic Update 9

a b whereas buccally ectopic canines are more

frequently identified in crowded cases.14
Other aetiological factors and associations
with canine ectopy include early loss
of the deciduous canine,15 failure of the
deciduous canine to resorb,5 narrowness
of the maxillary arch,16 Class II Division
2 malocclusions,16 clefts involving the
alveolus17 (Figure 6), root dilacerations,15
trauma,18 odontomata and deviated
Figure 4. Dental features associated with palatally impacted permanent canines: (a) diminutive adjacent premolar roots19 (Table 1).
permanent maxillary right lateral incisor (note retained deciduous canine and absence of buccal canine
bulge; (b) developmentally absent permanent maxillary lateral incisors – note that only the 3/ has
become palatally impacted, whilst the /3 has erupted within the line of the arch.
Diagnosis of ectopic and
impacted permanent maxillary
canines
Clinical examination
All patients aged 9 years and
upwards should undergo an orthodontic
examination. As part of this process, the
eruption of the maxillary permanent
canines should be investigated to establish
the three ‘P’s:
n Presence;
n Position; and
n Pathology.
There are several clinical features that
are indicative of ectopic/impacted
permanent maxillary canines (Table 2). The
identification of a buccal or palatal bulge on
palpation is the most important information
that should be collected. Both sides should
be palpated and any asymmetric differences
Figure 5. The 3/ erupting normally despite the 2/ being developmentally absent. (Note the palatally should raise suspicion.
ectopic /3, although the /2 is present and of a normal size.) Definite buccal and palatal
bulges are indicative of buccally and
palatally positioned canines, respectively
(Figures 7 and 8). Occasionally, the
permanent canine can be palpated high
in the buccal sulcus and, in older children
and adults, this usually indicates a buccally
ectopic canine. Palpation is a tactile skill
that requires to be developed over time.
Buccally, the clinician should be careful
not to confuse the first premolar crown or
the lateral incisor root with the unerupted
permanent canine. However, the permanent
maxillary canines are not always buccally
palpable in 9-year-old children. Up to 30%
of children do not possess a buccal canine
bulge at the age of 10 years, whilst this
reduces to 5% in 11 year-olds and 4% in
those older than 12 years.20 This latter figure
includes canines that, by this stage, are
impacted. The clinical pathway for assessing
Figure 6. Impacted permanent maxillary canine in a patient with cleft lip and palate affecting the alveolus.
unerupted permanent maxillary canines is
(Note that all four second premolars are developmentally absent and that E/ is grossly carious.)
shown in Figure 9.
Other clinical information,
such as the eruption of the contralateral
has been suggested that these anomalies 2/ being developmentally absent, the permanent canine, premolars and second
provide additional space for the developing 3/ is erupting normally whilst the /3 is molars, the asymmetric inclination/
canine to migrate palatally.14 This is by palatally ectopic. Furthermore, palatally angulation, colour and rotation of the
no means universal (Figure 4b). Figure 5 ectopic canines are more often found in permanent lateral incisors, and mobility
demonstrates a case where, despite the uncrowded and spaced maxillary arches, of the deciduous canines, should alert the
10 Orthodontic Update
n Diminutive (peg-shaped) permanent maxillary lateral incisors.
n Developmentally absent permanent maxillary lateral incisors.
n Spaced or narrow maxillary arch.
n Early loss or failure of resorption of the deciduous maxillary canine.
n Class II Division 2 malocclusions.
n Oral clefts involving the alveolus.
n Dilaceration of the permanent canine root.
n Previous dento-alveolar trauma.
n Pathology impeding canine eruption.
n Deviated adjacent premolar roots.
Table 1. Risk factors in the development of ectopic permanent maxillary canines.
Developmentally normal
Palpation Palpable buccally
Deciduous canine Mobility/exfoliation
Permanent lateral May be tipped distally
incisor
Radiographic 1. Vertical resorption of
examination canine root
2. Permanent maxillary
canine crown positioned
between maxillary lateral
incisor and first premolar
Developmental Erupting age 11-13
age
Table 2. Differentiation between developmentally normal and ectopic/impacted permanent maxillary
canines
clinician to a potentially ectopic canine
(Figures 8, 10). Although comparison should
be made with the contralateral side, the
clinician should be alert to the possibility
of bilateral ectopia (Figure 11), which is
estimated to occur in 8% of cases.15
Radiographic examination
If, by age 10, the permanent
maxillary canine cannot be palpated
buccally, a radiographic investigation is
required. Most orthodontists and dental
radiologists recommend that two different
views are recorded and the parallax
principal using occlusal, panoramic,
cephalometric or periapical is employed.21
Although both vertical and
horizontal parallax are equally effective,
vertical parallax using a combination of
Ectopic/Impacted
Not palpable buccally, or
alternatively palpable either palatally
or high in the buccal sulcus
Absence of mobility around age 11-13
Distal tipping, discoloration or rotation
1. Either non-vertical or no resorption
of the deciduous canine root
2. Canine crown overlapping adjacent
incisor roots
3. Resorption of adjacent incisor roots
4. Magnification of the permanent
maxillary canine crown on a
panoramic radiograph
5. Parallax confirming buccal or palatal
ectopia/impaction
Unerupted at age 16
panoramic and occlusal radiographs is
advantageous (Figure 12). This is because
periapical radiographs of unerupted
canines (used for horizontal parallax)
often fail to demonstrate the root and
crown on the same image (Figure 2b)
– essential for accurate localization of the
crown and root. Moreover, the panoramic
radiograph frequently provides other useful
information, including the presence of third
molars, root morphology, undiagnosed
caries and interdental bone levels; factors
that can influence treatment planning
decisions (Figure 2a). Furthermore, in
addition to facilitating vertical parallax,
the occlusal image allows radiographic
comparison with the contralateral side
(Figure 12b). This can be of particular use
when localizing bilaterally impacted canines
January 2008
Figure 7. Pronounced buccal canine bulges.
Figure 8. Palatal bulging associated with an
impacted permanent maxillary left canine. (Note
that the rotated/proclined permanent lateral
incisor, the retained deciduous canine, and the
contralateral permanent canine and all the
premolars and permanent second molars are fully
erupted.)
(Figure 11).
Table 2 demonstrates the
radiographic differences between
developmentally normal and ectopic/
impacted permanent maxillary canines.
The permanent canine radiographically
overlapping the lateral incisor is widely
accepted as being the cardinal sign of
ectopy and impaction. However, ectopy is
also indicated by the deciduous canines
not being resorbed vertically, or where
the unerupted canine is magnified on a
panoramic radiograph or has an increased
horizontal angulation5 (Figure 11). Cone-
beam computed tomography (CBCT)
offers an alternative to conventional
radiography for the localization of ectopic
and impacted teeth.8 Because of the
three-dimensional nature of the image
format, unerupted permanent canines
that are ectopic and impacted are clearly
discernible. Unfortunately, CBCT images
necessitate a higher radiation dose (50
microsieverts22) to the patient than those
required for a combination of a dental
panoramic tomogram and occlusal (9–36
microsieverts23).
Following the localization of
unerupted, normally positioned, ectopic
or impacted permanent maxillary canines,
it is important to manage the patient
appropriately in order to achieve an optimal
January 2008
Figure 9. Clinical pathway for assessing unerupted permanent maxillary canines.
occlusal outcome. The chosen option will
depend on the individual patient’s dental
development and oral health status (Figure
13a), the position of both permanent
maxillary canines, other occlusal features
requiring orthodontic treatment (Figure
13b), patient motivation and expectation,
and radiographic features (including root
dilaceration, canine crown and incisor
resorption).
Management of the unerupted
maxillary canine
Developmentally normal canines
During the mixed dentition
Orthodontic Update 11
Figure 10. Distal tipping of the maxillary left
permanent lateral incisor associated with an
ectopic permanent canine. (Note the absence of
a buccal bulge.)
is required for other occlusal anomalies,
a time limit (usually age 16) should be
agreed with the patient and parents when
surgical intervention could be considered
to expedite orthodontic treatment. The
surgical and orthodontic details are
considered in the second part of this article.
Ectopic permanent maxillary canines
Extraction of the deciduous maxillary canine
Judicious extraction of the
deciduous maxillary canine is arguably
the most successful technique used in
interceptive orthodontics. This treatment
has been shown to prevent palatally
ectopic permanent canines from becoming
impacted by normalizing the eruption
pathway in 78% of Ericson and Kurol’s
series of 46 cases.25 However, success is
dependent on two important factors, the
position of the permanent maxillary canine
crown relative to the permanent lateral
incisor root and the age of the patient.
Where the maxillary permanent canine
crown was radiographically distal to the
midline of the maxillary lateral incisor
(Figure 15), extraction of the deciduous
maxillary canines was successful in 91%
of occasions. This dropped to 64% where
the canine crown was mesial to the
midline of the maxillary lateral incisor25
(Figure 16). More recent studies showed
stage, unerupted permanent maxillary
that extraction of deciduous maxillary
canines in the line of the arch frequently
canines is only successful in 50–62% of
cause fanning of the incisors and may be
cases.26,27 Nonetheless, in the study by
associated with a midline diastema. These
Power and Short,26 a further 15% improved
features often spontaneously resolve on
their position. Crucially, extraction of the
eruption of the canines and alignment of
deciduous maxillary canine should only be
the maxillary labial segment during this
considered for patients between the ages
normal developmental stage may result in
10–13 years. In patients older than 14 years,
iatrogenic resorption of the lateral incisor
the position of a palatally ectopic canine
roots or may, in fact, precipitate impaction
is unlikely to improve with the extraction
of the maxillary canines.24
of the deciduous canine. Consequently,
In older patients, where
the canine is not ectopic, short-term
alternative treatment options should be
considered.25
observation is appropriate (Figure 14).
In contemporary practice,
Nevertheless, where orthodontic treatment
patients and parents should be made aware
12 Orthodontic Update
Figure 11. Bilaterally ectopic permanent maxillary canines.
a by extractions or distal movement of the
b space maintenance should be instituted.
Furthermore, unless the dentition is spaced,
the contralateral deciduous canine tooth
should simultaneously be extracted to
prevent any unwanted centre line shift.
Follow-up is essential and
a further radiographic examination is
recommended if the permanent maxillary
canine has not erupted within a year of the
deciduous canine being removed. This will
allow the unerupted permanent canine to
be localized again, and the new position to
be compared with the previous radiographs.
If no radiographic improvement in position
has occurred within this year, then no
Figure 12. (a, b) Vertical parallax using a further improvement can be anticipated.26
combination of occlusal and panoramic At this stage, alternative treatment options
radiographs: (a) DPT view, (b) occlusal view. (Note should be considered, such as surgical
1: The canine tip moves in the same direction as exposure and orthodontic traction (see
the radiographic tube between the two images Part 2). Nevertheless, in many cases, where
and Note 2: The radiographic magnification of the permanent maxillary canine fails to
the maxillary right permanent canine on the erupt following removal of the deciduous
panoramic image due to its palatal position.) predecessor, the position of the unerupted
permanent canine will improve, and is
usually more superficial and relatively
amenable to surgical exposure (Figure 15b).
that, despite removal of the deciduous
Moreover, as resorption of the adjacent
canine at the optimal age, some permanent
permanent incisor roots is not usually
maxillary canines still fail to erupt normally.
detectable clinically until at an advanced
January 2008
stage, and as it is usually symptom free,28
early follow-up will allow incisor resorption
to be identified and appropriately managed
at an early stage.
Extraction of the deciduous
maxillary canine can also normalize the
eruption pathway of buccally ectopic
permanent maxillary canines, however this
is less predictable than when instituted for
palatally ectopic maxillary canines. This is
because of the variability in positioning
of buccally ectopic permanent maxillary
canines.
Space creation
In cases of maxillary arch
crowding, the creation of additional space
buccal segments27 may also be necessary
to normalize the eruption pathway of
the permanent canine. Indeed, recent
evidence suggests that the combination
of extraction of the deciduous canine and
cervical headgear increases the chances of
eruption of ectopic permanent maxillary
canines to 80%.27 The removal of the first
premolar tooth, where necessary for relief
of crowding, can be conducted at the same
time as the deciduous maxillary canine is
removed. This interceptive method is more
useful for buccally placed canines, where
the eruption of the permanent maxillary
canine is more guaranteed in comparison to
palatally ectopic canines. Where necessary,
Follow-up is essential. Patients and parents
should be advised that eruption is by
no means guaranteed and, if the canine
fails to erupt within one year, further
intervention will probably be necessary
although, in most instances, the canine will
have improved its position, making later
exposure considerably easier.
If the permanent maxillary
lateral incisor is either diminutive or has
suffered extensive resorption (Figure 1),
it may be better to remove this tooth in
preference to a sound first premolar to
allow the permanent maxillary canine to
erupt adjacent to the permanent central
incisor.29 Where the permanent maxillary
lateral incisor is developmentally absent
and ‘space closure’ is planned (Figure 4b
illustrates such a case), then the deciduous
lateral incisor should be removed at the
same time as the deciduous canine, to allow
the permanent maxillary canine to erupt
adjacent to the permanent central incisor.
This minimizes later orthodontic treatment.
In cases where the unerupted
permanent maxillary canine causes
extensive resorption of the permanent
central incisor, consideration should
be given to early extraction of the
January 2008 Orthodontic Update 13

a b

compromised incisor and encouraging the

Figure 13. Ectopic permanent maxillary canines in a ten-year-old patient: (a) the untreated caries; and
(b) the unerupted permanent left maxillary central incisor are higher treatment priorities.
a first premolar teeth (Figure 17), or the
Figure 14. Developmentally normal canines.
The left permanent maxillary canine was not
palpable buccally but was resorbing the root of
the deciduous canine normally. The permanent
canine would be expected to erupt within nine
months: (a) clinical appearance; (b) radiographic
appearance.
b Impacted permanent maxillary canines
canine to erupt into the space, accepting
that the morphology of the canine will
require to be modified to resemble a
permanent central incisor.
Transpositions usually involve
the permanent maxillary canine and
permanent maxillary canine and the
permanent lateral incisor tooth. Invariably,
these should be accepted. Where necessary,
space should be made available to allow
the transposed canine to erupt (Figure 18),
accepting that coronal ‘remorphologizing’
will be necessary later for optimal aesthetics
and function.
When interceptive treatment
is not successful, or when adolescent and
adult patients present with impacted
permanent maxillary canine teeth, several
treatment options are available. These
include surgical exposure and orthodontic
traction, long-term monitoring, surgical
removal, autotransplantation. These and a
number of other miscellaneous treatment
options are considered in Part 2 of this
article.

Acknowledgement
The author would like to thank
Mrs CM Burnett of Medical Computing and
Media Services at the University of Dundee
for her help with the production of many of
the illustrations.

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14 Orthodontic Update
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Book Review
An Introduction to Orthodontics 3rd
edn. By Laura Mitchell. Oxford: Oxford
University Press, 2007. (£42.99). ISBN
978-0-19-856812-4.
This book, now in its third edition, provides
an excellent introduction to the study
and practice of orthodontics. Aimed
originally at the undergraduate student
and general dental practitioner, the text
has attained a level of detail that serves as
a sound introduction to orthodontics for
postgraduate students embarking on a
career in the specialty.
The book is divided into 23
chapters which traverse the main subject
areas in the specialty: the early chapters
cover the aetiology of malocclusion, facial
growth and orthodontic assessment and
treatment planning. There follow chapters
on the different malocclusions and
modus operandi of the main orthodontic
appliance systems. Later, more specialist
subjects such as orthognathic surgery,
the management of cleft lip and palate
and adult orthodontics are summarized. A
final chapter on ‘orthodontic first aid’ is a
useful addition, particularly to the nascent
Cochrane Synopses
ORTHODONTIC AND ORTHOPAEDIC
TREATMENT FOR ANTERIOR OPEN BITE IN
CHILDREN
Lentini-Oliveira DA, Carvalho FR, Ye Q, Luo J,
Saconato H, Machado MAC, Prado LBF, Prado
GF. Orthodontic and orthopaedic treatment
for anterior open bite in children. Cochrane
Database of Systematic Reviews 2007, Issue
2. Art. No.: CD005515. DOI: 10.1002/14651858.
CD005515.pub2.
‘Interventions were able to correct anterior
open bite but this was based on data from
two studies that have problems in their
quality.
Open bite is characterised by a
lack of vertical overlap of the upper and lower
incisors. This problem has several possible
causes such as mouth breathing, sucking
habits, alteration of development of jaw and
extraction of the primary canines. Eur J
Orthod 1988; 10: 283–295.
26. Power SM, Short MB. An investigation
into the response of palatally displaced
canines to the removal of deciduous
canines and an assessment of factors
contributing to favourable eruption.
Br J Orthod 1993; 20: 215–223.
27. Leonardi M, Armi P, Franchi L, Baccetti T.
Two interceptive approaches
to palatally displaced canines: a
prospective longitudinal study. Angle
practitioner: the chapter explains how to
manage the orthodontic ‘casual’ patient
and runs through the most common
presentations and suggests what action to
take.
The book is well written with
a sound foundation in the contemporary
literature whilst upholding current
opinion. There are plenty of diagrams
and clinical photographs for illustration.
It is quite apparent that the book has
been written by practising clinicians
who base their treatment plans and
appliance prescriptions on techniques that
consistently work.
Care has been taken to guide
those who choose to use the book for
reference: the sub-heading of each
chapter is listed in the contents, there is
a comprehensive index and all chapters
end with a list of contemporary references.
These latter are partially annotated to
guide any reader who may wish to study in
more depth.
A small criticism is that, where
the text quotes from the literature, the
references are not directly cited: this
approach keeps the text flowing but is a
maxilla. It can make speech, swallowing,
mastication and aesthetics difficult. Several
treatments have been used to correct
anterior open bite. The review authors
evaluated three studies with the following
treatments: Frankel’s function regulator-4
(FR-4) with lip-seal training, palatal crib with
chincup, and repelling-magnet splints versus
bite-blocks. This last study could not be
analysed because the author interrupted the
treatment earlier than planned due to side
effects.’
ADHESIVES FOR FIXED ORTHODONTIC
BANDS
Millett DT, Glenny AM, Mattick CR, Hickman J,
Mandall NA. Adhesives for fixed orthodontic
bands. Cochrane Database of Systematic
Reviews 2007, Issue 2. Art. No.: CD004485.
DOI: 10.1002/14651858.CD004485.pub3.
Orthodontic Update 15
Orthod 2004; 74: 581–586.
28. Rimes RJ, Mitchell CN, Willmot DR.
Maxillary incisor root resorption
in relation to the ectopic canine: a
review of 26 patients. Eur J Orthod
1997; 19: 79–84.
29. Sasakura H, Yoshida T, Murayama S,
Hanada K, Nakajima T. Root resorption
of upper permanent incisor caused
by impacted canine. An analysis of
23 cases. Int J Oral Surg 1984; 13:
299–306.
slight irritation for the reader who would
like to refer back to an original article.
Apart form this small point the book is
an excellent read for all those interested
in orthodontics and I would readily
recommend it to all concerned.
John Turner
Birmingham Dental Hospital
‘There is insufficient evidence to determine
the most effective adhesive for attaching
orthodontic bands to molar teeth in patients
with full arch fixed orthodontic appliances
Orthodontic treatment involves
using fixed or removable appliances (braces)
on teeth to correct their position. It has been
shown that the quality of treatment result
obtained with fixed dental appliances is much
better than with removable appliances. The
success of a fixed dental appliance depends
on the metal attachments (brackets and
bands) being securely attached to the teeth
so that they do not become loose during
treatment. Brackets are usually attached to
teeth other than molars, where bands (metal
rings that go round the teeth) are more
commonly used. There is insufficient evidence
with regard to the most effective adhesive for
attaching orthodontic bands to molar teeth.’