ORIGINAL ARTICLE

The labiopalatal impacted canine:

Accurate diagnosis based on the position
and size of adjacent teeth: A cone-beam
computed tomography study
Stella Chaushu,a Mikaela Vryonidou,a Adrian Becker,a Avi Leibovich,a Eyal Dekel,a Nimrod Dykstein,b
Ludovica Nucci,c and Letizia Perillod
Jerusalem and Tel Aviv, Israel, and Naples, Italy

Introduction: Labiopalatal impacted canines (L-PICs) occur when the canines lie between central and lateral
incisors, with their tip palatal to the central incisor and part of their crown labial to the lateral incisor. Because
of their unusual position, they are often misdiagnosed, and their orthodontic resolution fails. This study aims
to provide clinicians with pathognomonic features for early and accurate positional diagnosis of L-PICs.
Methods: The L-PIC sample included 21 subjects with full diagnostic records. The control group of normally
erupted canines was taken from a previous study. Clinical photographs, 2-dimensional radiographs, and
cone-beam computed tomography were used to evaluate the positions of the adjacent incisors and first
premolars, the canine incisor index, and the mesiodistal width of the lateral vs central incisors. Results: Central
incisors adjacent to L-PICs showed significant mesial root angulation, labial root inclination, and mesiolabial
crown rotation, whereas lateral incisors presented significant distal root angulation, palatal root inclination,
and mesiolabial crown rotation, in comparison to controls. The roots of the central and lateral incisors were diver-
gent, in contrast to the controls, in which they were slightly convergent. The first premolar positions were not
affected. The mean canine incisor index was significantly bigger in L-PICs vs the controls, suggesting a palatal
canine. The lateral incisor widths were similar between the groups. Conclusions: This study provides the ortho-
dontist with evidence-based clinical and radiographic red flags for diagnosing L-PIC, which may allow timely
initiation of orthodontic treatment and correct planning of mechanotherapy. (Am J Orthod Dentofacial Orthop
2023;163:690-9)

a
Department of Orthodontics, Hadassah Medical Center, Faculty of Dental
Medicine, Hebrew University, Jerusalem, Israel.
b
Department of Orthodontics, the Maurice and Gabriela Goldschleger School of
Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
c
Department of Orthodontics, University of Campania Luigi Vanvitelli, Naples,
Italy.
d
Multidisciplinary Department of Medical-Surgical and Dental Specialties,
University of Campania Luigi Vanvitelli, Naples, Italy.
Stella Chaushu and Mikaela Vryonidou are joint first authors and contributed
equally to this work.
Ludovica Nucci and Letizia Perillo are joint last authors and contributed equally
to this work.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Ethical approval was obtained from the Institutional Review Boards of the
Hadassah Medical Hospital (HMO-0300-20) and the University of Campania
Luigi Vanvitelli (protocol no. 225).
Address correspondence to: Stella Chaushu, Department of Orthodontics,
Hadassah Medical Center, Faculty of Dental Medicine, Hebrew University, PO
Box 12272, Jerusalem 91120; e-mail, Drchaushu@gmail.com or Drchaushu@
hadassah.org.il.
Submitted, December 2021; revised and accepted, May 2022.
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2022.05.021
690
T
he maxillary canines are the most frequently
impacted teeth after the third molars, and their
prevalence ranges from 1%-3%.1,2 They are
more common in females than in males, with a ratio of
3:1,3 and more often palatally than buccally impacted,
with a ratio from 6:1 to 9:1.4
Timely diagnosis of the impaction, approximately
when aged 9-10 years, is crucial for initiating preventive
measures to encourage spontaneous canine eruption or
to reduce the severity of the impaction, facilitate ortho-
dontic resolution, and reduce the risk of side effects. Pre-
ventive and interceptive treatments include extraction of
primary canines,5,6 space opening by rapid palatal
expansion,7,8 use of cervical pull headgear for distaliza-
tion of molars,9,10 proclination of incisors,3 space main-
tenance with transpalatal arch11 and extraction of first
premolars as part of serial extraction treatment.12 In
contrast, late diagnosis and the absence of monitoring
and management of the impacted canine may cause se-
vere complications, such as displacement and resorption
Chaushu et al
Fig 1. Three-dimensional view of a typical L-PIC patient.
of the adjacent roots,13,14 recurrent infections, follicular
cysts,15,16 compromised periodontal condition of the
adjacent teeth17 and shortening of the dental arch.18
Late diagnosis is also related to a longer, more complex,
painful, and expensive treatment, sometimes involving
several surgical procedures.19-21 The first step in
achieving an early diagnosis of an impacted maxillary
canine and its location is recognizing its clinical
pathognomonic features. Palatally-impacted canines
(PICs) and buccally impacted canines (BICs) have
different etiologies and characteristics. PICs are associ-
ated with anomalous (missing, peg-shaped, or small)
lateral incisors, aplasia of second premolars, infraocclu-
sion of primary molars, small and missing teeth, and
delayed dental age,22-26 whereas BICs are usually
associated with large teeth and crowding.4,22,27 PICs
and BICs are associated with different typical positions
of ipsilateral central incisors,28 lateral incisors, and first
premolars.29 The second step is a radiographic assess-
ment of the impaction using 2-dimensional (2D) views,
such as periapical, panoramic, and cephalometric
x-rays. Next, 3-dimensional (3D) imaging by cone-
beam computerized tomography (CBCT) can be advised
for a more accurate positional diagnosis, detection of
resorption of the canine or adjacent roots, and other
pathologies.30,31 However, CBCT imaging should be
judiciously prescribed because of its higher irradiation
dose, estimated as 2-4 times more than a panoramic
radiograph.31,32 This study focuses on a distinct group
of impacted maxillary canines, termed labial-palatal
impacted canines (L-PICs) (Fig 1). L-PIC occurs when
the canine lies labial to the lateral incisor, and its crown
tip is palatal to the central incisor. L-PICs are not
frequent, but they represent a distinct entity and are
associated with a degree of canine or lateral incisor
American Journal of Orthodontics and Dentofacial Orthopedics
691
transposition, which may be partial or complete.33,34
Because of their unusual and challenging position they
are often misdiagnosed by even the most experienced
clinicians.
Consequently, their orthodontic resolution may fail
because of inappropriate surgical exposure and mecha-
notherapy. Mistaken positional diagnosis and an erro-
neous direction of the orthodontic force have been
reported as the second most common factor attributed
to failure to resolve maxillary canine impaction.35 This
study aimed to describe the clinical and radiographic
features of L-PICs, focusing on the typical positions
and size of the adjacent teeth, which will provide the
practitioners with clear diagnostic clues for their accu-
rate diagnosis and correct planning of the treatment
strategy.
MATERIAL AND METHODS
This retrospective observational study was carried out
on pretreatment records of patients presenting with
L-PICs. An initial sample of 38 subjects with L-PICs
was gathered. Among them, 21 patients (mean age
13.5 years, 11 females and 10 males) had full diagnostic
records, including high-quality CBCTs, and they
comprised the final experimental sample.
The positions of the central incisors, lateral incisors,
and first premolars were evaluated in intraoral photo-
graphs, panoramic and cephalometric views and then
validated in CBCTs; the widths of the L-IPC and the ipsi-
lateral central incisor were measured in panoramic
views; the widths of the central and lateral incisors
were measured in CBCTs (Fig 2).
The control group of patients with normally erupted
canines (mean age 14.0 years) was taken from a larger
control group used in a previous study29 and was
aged- (6 0.5 years) and gender-matched to this study
group. The data were obtained from the Department
of Orthodontics of the Hebrew University, Hadassah
School of Dental Medicine, Jerusalem, Israel, and from
the Multidisciplinary Department of Medical-Surgical
and Dental Specialties, Department of Orthodontics of
the University of Campania Luigi Vanvitelli, Naples, Italy.
Ethical approval was obtained from the Institutional
Review Boards of the Hadassah Medical Hospital (HMO-
0300-20) and the University of Campania Luigi Vanvi-
telli (protocol no. 225). If underaged, all patients or their
parents signed a consent form authorizing the institu-
tions to use all records before starting treatment for
this research project.
The final sample was selected on the basis of inclu-
sion criteria (the presence of L-PIC verified by CBCT, a
fully erupted first premolar, and high-quality
May 2023  Vol 163  Issue 5
692
Fig 2. Evaluation of central and lateral incisors and first premolar positions: A-C, Intraoral photo-
graphs; D, Panoramic view; E, Lateral cephalometric view; F-H, CBCT.
orthodontic records) and exclusion criteria (previous
orthodontic treatment, craniofacial syndromes, cleft
lip and palate, dental trauma to anterior teeth, and
cysts or other pathologies of the impacted and adja-
cent teeth).
The CBCTs were taken with either of 2 CBCT systems:
Cranex 3Dx (Soredex Oy, Tuusula, Finland) with a small
field-of-view (5 3 5 cm) and a resolution (voxel size) of
0.2 mm 3D Accuitomo FPD80/ACCU (Morita, Kyoto,
Japan), with small field-of-view (5 3 5 cm), and resolu-
tion (voxel size) of 0.2 mm. The 3 reference planes were
identified according to a previous study.29
The dependent variables were as follows:
1. Clinical evaluation (intraoral photographs) (Figs 2,
A-C).
Frontal view (Fig 2, A): angulation of central and
lateral incisors—the angle between the long axis of the
crown and the midline—a vertical line passing perpen-
dicular to the occlusal plane, passing between the maxil-
lary central incisors; the angle between the long axes of
the central and lateral incisors’ crowns.
Occlusal view (Fig 2, B): rotation of central and
lateral incisor and first premolar—the angle between a
line tangent to the labial aspect of the crown and a mid-
palatal line parallel to the midpalatal suture.
Lateral view (Fig 2, C): the inclination of central and
lateral incisors—the angle between the long axis of the
May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chaushu et al
crown and the occlusal plane; angulation of the first pre-
molar—the angle between the long axis of the crown and
the occlusal plane.
2. Radiographic evaluation (panoramic views) (Fig 2, D):
Angulation of central and lateral incisors—the angle
between the long axis of the root and the midline—a ver-
tical line passing perpendicular to the palatal plane,
passing through the anterior nasal spine. The angle
was labeled positive when the roots were mesially angu-
lated and negative when the roots were distally angu-
lated; the angle between the central and lateral
incisors’ roots. The angle was labeled positive when
the roots were convergent and negative when the roots
were divergent; canine incisor index—the ratio between
the maximal mesiodistal width of the L-PIC and the ipsi-
lateral central incisor.36
3. Radiographic evaluation (lateral cephalometric
views) (Fig 2, E):
The inclination of central and lateral incisors—the
angle between the long axis of the root and the Frank-
furt plane; the angle between the long axes of the cen-
tral and lateral incisors’ roots.
4. Radiographic evaluation (CBCT scans) (Fig 2, F-H):
Axial view (Fig 2, F): Rotation of central and lateral
incisors—the angle between a tangent to the facial
Chaushu et al 693

Table I. Clinical evaluation of the adjacent teeth position in intraoral photographs: comparison between L-PIC and
control groups ( )
Angle Impacted Control Difference P value
Frontal View
Central incisor angulation 5.29 6 9.61 9.59 6 2.24 14.88 0.0001***
Lateral incisor angulation 7.63 6 15.31 7.95 6 4.29 15.58 0.002**
Central incisor lateral incisor 11.50 6 20.65 23.19 6 4.43 34.69 0.0004***
Lateral View
Central incisor inclination 84.14 6 10.65 78.27 6 6.41 5.87 0.0635
Lateral incisor inclination 59.42 6 14.20 71.69 6 7.05 12.27 0.004**
First premolar angulation 80.44 6 7.82 79.02 6 9.37 1.42 0.6495
Occlusal View
Central incisor rotation 66.78 6 12.03 78.96 6 11.13 12.18 0.0083**
Lateral incisor rotation 41.64 6 16.07 51.82 6 11.11 10.18 0.0399*
First premolar rotation 71.18 6 9.57 72.85 6 8.19 1.673 0.5833
Note. Values are mean 6 standard deviation.
*P \0.05; *P \0.01; ***P \0.001.

contour and the midpalatal plane; rotation of the first
premolar—the angle between a line connecting the
most prominent point on the buccal and lingual surfaces
of the crown and the midpalatal plane; width of central
and lateral incisors’ crowns—the distance between the
mesial and distal tips of the crown measured at the
incisal edge.
Coronal view (Fig 2, G): Angulation of central and
lateral incisors—the angle between the long axis of the
root and the midpalatal plane; inclination of the first
premolar—the angle created between the long axis of
the premolar and the midpalatal plane.
Sagittal view (Fig 2, H): Inclination of central and
lateral incisors—the angle between the long axis of the
incisor and the palatal plane; angulation of the first pre-
molar—the angle between the long axis of the premolar
and the palatal plane.
Statistical analysis
The 2D measurements were performed with ImageJ
software (version 1.52t; National Institutes of Health
and the Laboratory for Optical and Computational
Instrumentation, University of Wisconsin, Madison,
Wis). The 3D measurements were performed with Horos
software (Horos Project, Annapolis, Md) and GNU Lesser
General Public License (version 3.0). The statistical tests
were performed using GraphPad Prism (version 9.3;
GraphPad Software, La Jolla, Calif).
Two weeks after completing the data collection, the
CBCT scans of 8 patients were randomly selected using
online software (https://www.randomizer.org/) to
examine the intraobserver reliability. The intraclass
correlation coefficient was used to assess the consistency
and reproducibility of angular and linear measurements.
The data distribution of the different groups was
analyzed for normality. Consequently, independent t
tests were used to compare the variables in the L-PIC
and control groups that passed the normality tests.
Mann-Whitney U test was used to compare the variables
in the L-PIC and control groups that did not pass the
normality tests. The significance level was set at 0.05.
RESULTS
The intraclass correlation coefficient values were 0.92
for linear measurements and 0.98 for angular measure-
ments. Thus, all the measurements were considered
highly reliable.
Clinical evaluation (intraoral photographs) (Table I;
Fig 3): The crowns of the central incisors in the L-PIC
group showed a significant mesial angulation with a
mean difference of 14.88 (P \0.001), a significant me-
siolabial rotation with a mean difference of 12.18
(P \0.01), and a slightly labial inclination with a mean
difference of 5.87 , compared with the control group.
The crowns of the lateral incisors in the L-PIC group pre-
sented a significant distal angulation ( 7.63 ), with a
mean difference of 15.58 (P \0.01) compared to
the controls, a significant palatal inclination, with a
mean difference of 12.27 (P \0.01), and a significant
mesiolabial rotation of 41.64 (P \0.05). The central
and lateral incisors crowns in the L-PIC group were
divergent (mean, 11.50 ), whereas the control group
was convergent (mean, 23.19 ). The mean difference be-
tween the groups was 34.69 , which was highly statis-
tically significant (P \0.001). No significant differences
were found for the positions of the first premolar.
Radiographic evaluation (panoramic views) (Table II;
Fig 4): In the L-PIC group, central incisors exhibited a

American Journal of Orthodontics and Dentofacial Orthopedics May 2023  Vol 163  Issue 5
694 Chaushu et al

Fig 3. Intraoral photographs histograms: A-C, Frontal view; D-F, Lateral view; G-I, Occlusal view. Blue
and red represent the control and L-PIC groups, respectively.

Table II. Two-dimensional radiographical evaluation of adjacent teeth position and size in panoramic views: com-
parison between L-PIC and control groups ( )
Angle Impacted Control Difference P value
Central incisor angulation 9.29 6 4.72 5.47 6 1.89 14.76 0.0001***
Lateral incisor angulation 4.38 6 14.98 8.69 6 3.86 13.07 0.002**
Central incisor lateral incisor 10.69 6 17.71 11.38 6 1.73 22.76 0.0001***
Canine incisor index 1.17 6 0.16 0.98 6 0.08 0.1939 0.0001***
Note. Values are mean 6 standard deviation.
**P \0.01; ***P \0.001.

significant mesial root angulation (mean, 9.29 ) with
a difference of 14.76 compared with controls
(P \0.001), whereas lateral incisors showed a significant
distal root angulation with a mean of 4.38 and a dif-
ference of 13.07 compared with the control group
(P \0.01). The long axes of the roots of central and
lateral incisors showed a significant root divergence
(mean 10.69 ). The difference in the central and lateral
incisors angle between the L-PIC and the control groups
was 22.76 (P \0.001).
The mean canine incisor index was 1.17 vs 0.98 in the
control group (P \0.001).
Radiographic evaluation (lateral cephalometric
views) (Table III; Fig 5): central incisors in the L-PIC
group presented a labial root inclination, with a mean
difference of 5.06 , whereas lateral incisors displayed
a significant palatal root inclination, with a significant
difference of 10.0 (P \0.001) compared with controls.
In the L-PIC group, the angle between the long axes of
the roots of central and lateral incisors was significantly
larger than in the control group by a mean of 5.63
(P \0.05).
Radiographic evaluation (CBCT scans) (Table IV;
Fig 6): central and lateral incisors for the L-PIC group
showed a mesiolabial crown rotation, with a difference
of 9.54 and of 11.6 respectively, compared to con-
trols (P \0.01). Central incisors also showed a mesial
root angulation (P \0.001) with a mean of 8.07

May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chaushu et al
Fig 4. Panoramic views histograms: A, Central incisor angulation; B, Lateral incisor angulation; C,
Angle between central and lateral incisors’ roots; D, Canine incisor index ratio. Blue and red represent
the control and L-PIC groups, respectively.
Table III. Two-dimensional radiographical evaluation of adjacent teeth position in lateral cephalometric views: com-
parison between L-PIC and control groups ( )
Angle Impacted
Central incisor inclination 107.10 6 6.63
Lateral incisor inclination 127.10 6 7.36
Central incisor lateral incisor 17.43 6 7.30
Note. Values are mean 6 standard deviation.
*P \0.05; ***P \0.001.
compared with central incisors in controls which dis-
played slight distal root angulation ( 6.18 ). Lateral in-
cisors presented a very significant distal root angulation
with a mean difference of 13.07 and a significant
palatal root inclination, with a mean difference of
16.33 compared to controls (P \0.001). The posi-
tions of first premolars were not affected in the L-PIC
group.
The mean of the central and lateral incisors’ width ra-
tios was similar between the L-PIC and the control
groups (77.08% vs 75.08%, respectively).
DISCUSSION
For almost a century, the most widely recognized tech-
nique for initial and fast pinpointing the location of an
unerupted maxillary canine tooth has been Clark’s tube-
shift method,12,37 which is extremely simple and inexpen-
sive to perform. The technique employs a pair of periapical
radiographs of the same area, taken at different angles,
and uses the altered positional superimposition of the un-
erupted tooth on the adjacent erupted tooth on the 2 films
to diagnose their relative labiolingual positions. The prin-
ciple behind the method is the attempt to augment 2D
plane films using altered angulation to construct the third
dimension. Every undergraduate dental student and or-
thodontic resident has been taught the method, and its
virtues have been extolled in the literature.38,39 Neverthe-
less, Clark’s method will not recognize the unusual L-PICs’
American Journal of Orthodontics and Dentofacial Orthopedics
695
Control Difference P value
112.2 6 6.14 5.06 0.0370*
117.1 6 3.18 10.00 0.0004***
11.80 6 3.63 5.63 0.0314*
position and confuse clinicians by diagnosing them as
PICs. The second most common radiograph in the initial
diagnosis is the panoramic view. Chaushu et al36 showed
that by using the canine incisor index, accurate diagnosis
of PICs vs BICs could be achieved in approximately 88% of
the patients. A PIC will have a canine incisor index higher
than 1.15 because of the magnification of the PIC crown,
which is farther from the x-ray source than the central
incisor. In this article, the mean canine incisor index of
the L-PICs was higher than 1.15, erroneously implying a
palatal position.
The practical implications of such a misdiagnosis are
that an L-PIC will be surgically exposed from the wrong
side of the alveolar ridge, and orthodontic traction will
be applied in a hopeless direction. These examples will
generally end up as failures, and the patient may finally
lose the canine because it will have been drawn into an
intractable position. In addition, the adjacent lateral in-
cisors may be severely periodontally compromised
because of collateral damage being inflicted both by
the surgical exposure and subsequently by contact be-
tween its root and that of the canine, as the latter is be-
ing drawn through the palatal tissue.
To the best of our knowledge, this cross-sectional
study is the first to describe the clinical and radiographic
characteristic features of L-PICs, based on the positions
and size of the adjacent teeth. A comparison with the
few studies that evaluated the effects of impacted maxil-
lary canines on the 3D positions of adjacent
May 2023  Vol 163  Issue 5
696 Chaushu et al

Fig 5. Lateral cephalometric views histograms: A, Central incisor inclination; B, Lateral incisor
inclination; C, Angle between the long axes of the central and lateral incisors’ roots. Blue and red
represent the control and L-PIC groups, respectively.

Table IV. Three-dimensional radiographic evaluation of the adjacent teeth position and size in CBCT scans: compar-
ison between L-PIC and control groups ( )
Variables Impacted Control Difference P value
Central incisor
Rotation 68.82 6 7.81 78.36 6 11.22 9.54 0.004**
Angulation 8.07 6 7.09 6.18 6 2.98 14.25 0.0001***
Inclination 68.58 6 10.82 61.00 6 9.74 7.57 0.0343*
Lateral incisor
Rotation 42.55 6 12.96 54.15 6 8.41 11.6 0.003**
Angulation 1.16 6 15.75 14.24 6 4.09 13.07 0.0004***
Inclination 47.70 6 15.26 64.03 6 8.26 16.33 0.0003***
First premolar
Rotation 66.63 6 8.19 71.18 6 8.55 4.55 0.1080
Angulation 84.67 6 8.45 84.74 6 9.89 0.07 0.9766
Inclination 84.60 6 8.92 89.73 6 10.32 5.13 0.1090
Central incisor lateral incisor
Ratio 77.08 6 9.43 75.08 6 8.41 1.99 0.5177
Note. Values are mean 6 standard deviation.
*P \0.05; **P \0.01; ***P \0.001.

teeth28,29,40,41 shows that L-PICs display characteristics
of both palatal and buccal impactions.
The central incisors ipsilateral to L-PICs showed sig-
nificant mesiolabial rotation and mesial root angulation
in all records and labial root displacement. These
changes were similar to those recently reported for
PICs by Light et al.28
In contrast, the lateral incisors displayed a significant
palatal root displacement and a mesiolabial rotation,
typical of a buccal canine.28,29 The most important
and pathognomonic change in the position of lateral in-
cisors adjacent to L-PICs was the distal root inclination.
This distal angulation of the lateral incisors signifi-
cantly differed from the normal angulation previously
found in relation to a BIC29 and the mesial42,43 or
upright40 angulation found in PIC patients.
An etiologic explanation for these positional changes
relates to the tooth-eruption process itself. During the
“ugly duckling stage of development,” which usually oc-
curs when aged 7-8 years, the roots of the maxillary in-
cisors are generally tipped mesially because of the
influence of the canines’ crowns on their
apices.12,41,42,44 Later, the canine is guided down along
the distal aspect of the lateral incisor’s root toward its
crown to influence the incisors to gradually upright.
So, they lose their eruptive guidance when the canines
are labiopalatally displaced. Therefore, their labiopalatal
impaction produces a mesial force on the central inci-
sor’s root and a distal force on the lateral incisor’s root
that causes a mesial root angulation of the central
incisor and a distal root angulation of lateral incisor,
respectively. In agreement with this hypothesis, the

May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chaushu et al
Fig 6. CBCTs histograms: A-D, Central incisor rotation, angulation, inclination, and mesiodistal crown
width; E-H, Lateral incisor rotation, angulation, inclination, and mesiodistal crown width; I-M, First pre-
molar rotation, angulation, and inclination. Blue and red represent the control and L-PIC groups,
respectively.
authors found that in most of the L-PIC group’s patients,
the long axes of the roots of the central and lateral inci-
sors are divergent, in contrast to the controls.
No significant differences were found in the positions
of the first premolars, in contrast to a previous study in
which PICs was associated with mesiobuccally rotated
first premolar crowns. This result is probably because
of the anterior position of the L-PICs, which are distant
from the first premolar roots.
An additional finding in this study was that the lateral
incisors were found to be of normal size. Previous
studies showed that PICs are associated with reduced
volumes of the central and lateral incisors27,45,46 and
an increased prevalence of peg-shaped, small, or anom-
alous lateral incisors.1,40,43,47,48 BICs are usually adja-
cent to larger or normally-sized lateral incisors.27,49
This finding can be used as an additional clue in the dif-
ferential diagnosis of an L-PIC vs PIC.
This study showed that the initial orthodontic re-
cords, including intraoral photographs and panoramic
and lateral cephalometric x-rays, contain all information
necessary for the early diagnosis and differential diag-
nosis of L-PICs from either PICs or BICs. The 3D analysis
confirmed the measurements on the 2D records.
However, 2D imaging techniques impose limitations
American Journal of Orthodontics and Dentofacial Orthopedics
697
on detailed interpretation because of distortion, arti-
facts, and superposition,18 whereas CBCT scans provide
additional information on the relationship between the
impacted canine and the roots of the neighboring teeth
along the full length of the root. Moreover, it also allows
the detection of the possible presence and extent of the
resorption on the palatal side of the central incisors and
the buccal side of the lateral incisors’ roots, which are
hidden in the labiolingual plane by the superimposition
of the impacted canine.5,36
Knowledge of the typical displacement of the
incisor roots adjacent to L-PICs is crucial while plan-
ning the mechanotherapy strategy, to shorten the
duration, minimize potential damage, and avoid fail-
ure. Because of their mesiodistal displacement, the
L-PICs should be exposed from the labial side with a
partial thickness flap raised from the keratinized
gingiva of the crest of the ridge,17 and traction should
be applied first distolabially to distance the canine tip
from the palatal side of the central incisors, and then
distally to by-pass the roots of the lateral incisors. Dur-
ing these stages, the roots of the lateral incisors should
be maintained in their distal inclination and palatal
displacement, meaning that they should not be bonded
or bonded passively.17 In severe examples, the root
May 2023  Vol 163  Issue 5
698
divergence may initially need to be increased to enlarge
further the window of opportunity between the roots
of the 2 incisors.12
The main limitations of this study were its retrospec-
tive nature with the related medium level of evidence,
the risk of bias in selecting the patients and sample
size. Nevertheless, considering the rarity of the L-PIC
cases, the sample size should be considered acceptable.
CONCLUSIONS
The article provides evidence-based clinical and
radiographic pathognomonic features for accurate diag-
nosis of L-PICs, on the basis of the position and size of
the adjacent teeth. The most significant features were
the distal and palatal root displacement of the adjacent
lateral incisors and the mesial root angulation of the
adjacent central incisors. Consequently, in most of the
patients, the roots of the central and lateral incisors
were divergent, in contrast to the control sample and
the typical palatal or buccal impacted canines’ groups,
in which the long axes of the roots were mostly conver-
gent, tipped toward the palatal midline. Both central and
lateral incisors showed a mesiolabial crown rotation.
Furthermore, the lateral incisors were normally sized in
all patients.
AUTHOR CREDIT STATEMENT
Stella Chaushu contributed to conceptualization,
methodology, resources, investigation, supervision,
original draft preparation, and manuscript review and
editing; Mikaela Vryonidou contributed to investigation
and original draft preparation; Adrian Becker contrib-
uted to conceptualization, resources, and manuscript re-
view and editing; Avi Leibovich contributed to formal
analysis and manuscript review and editing; Eyal Dekel
contributed to software, data curation, and validation;
Nimrod Dykstein contributed to resources; Letizia Perillo
contributed to resources, investigation, supervision,
original draft preparation, and manuscript review and
editing; Ludovica Nucci contributed to investigation,
formal analysis, original draft preparation, and manu-
script review and editing.
REFERENCES
1. Brin I, Becker A, Shalhav M. Position of the maxillary permanent
canine in relation to anomalous or missing lateral incisors: a pop-
ulation study. Eur J Orthod 1986;8:12-6.
2. Ericson S, Kurol J. Radiographic assessment of maxillary canine
eruption in children with clinical signs of eruption disturbance.
Eur J Orthod 1986;8:133-40.
3. Becker A. Etiology of maxillary canine impactions. Am J Orthod
1984;86:437-8.
May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Chaushu et al
4. Jacoby H. The etiology of maxillary canine impactions. Am J Or-
thod 1983;84:125-32.
5. Ericson S, Kurol J. Early treatment of palatally erupting maxillary
canines by extraction of the primary canines. Eur J Orthod 1988;
10:283-95.
6. Power SM, Short MB. An investigation into the response of pala-
tally displaced canines to the removal of deciduous canines and
an assessment of factors contributing to favourable eruption. Br
J Orthod 1993;20:215-23.
7. Olive RJ. Orthodontic treatment of palatally impacted maxillary
canines. Aust Orthod J 2002;18:64-70.
8. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treat-
ment of palatal impaction of maxillary canines with rapid maxillary
expansion: a randomized clinical trial. Am J Orthod Dentofacial
Orthop 2009;136:657-61.
9. Leonardi M, Armi P, Franchi L, Baccetti T. Two interceptive ap-
proaches to palatally displaced canines: a prospective longitudinal
study. Angle Orthod 2004;74:581-6.
10. Baccetti T. Risk indicators and interceptive treatment alternatives
for palatally displaced canines. Semin Orthod 2010;16:186-92.
11. Baccetti T, Sigler LM, McNamara JA Jr. An RCT on treatment of
palatally displaced canines with RME and/or a transpalatal arch.
Eur J Orthod 2011;33:601-7.
12. Becker A. Orthodontic treatment of impacted teeth. 4th ed.
Chichester: Wiley-Blackwell; 2022.
13. Ericson S, Kurol J. Radiographic examination of ectopically erupt-
ing maxillary canines. Am J Orthod Dentofacial Orthop 1987;91:
483-92.
14. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused
by ectopic eruption of the canines. A clinical and radiographic
analysis of predisposing factors. Am J Orthod Dentofacial Orthop
1988;94:503-13.
15. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 4th
ed. Philadelphia: WB Sauders; 1983.
16. Chaushu S, Kaczor-Urbanowicz K, Zadurska M, Becker A. Predis-
posing factors for severe incisor root resorption associated with
impacted maxillary canines. Am J Orthod Dentofacial Orthop
2015;147:52-60.
17. Becker A, Chaushu S. Surgical treatment of impacted canines:
what the orthodontist would like the surgeon to know. Oral Max-
illofac Surg Clin North Am 2015;27:449-58.
18. Akkuc S, Duruk G, Duman S. Evaluation of impacted canines’
localization and adjacent lateral incisors’ root resorption with or-
thopantomography and cone-beam computed tomography. Oral
Radiol 2021;37:476-86.
19. Bjerklin K, Kurol J, Valentin J. Ectopic eruption of maxillary first
permanent molars and association with other tooth and develop-
mental disturbances. Eur J Orthod 1992;14:369-75.
20. Zuccati G, Ghobadlu J, Nieri M, Clauser C. Factors associated with the
duration of forced eruption of impacted maxillary canines: a retro-
spective study. Am J Orthod Dentofacial Orthop 2006;130:349-56.
21. Barlow ST, Moore MB, Sherriff M, Ireland AJ, Sandy JR. Palatally
impacted canines and the modified index of orthodontic treatment
need. Eur J Orthod 2009;31:362-6.
22. Becker A, Chaushu S. Etiology of maxillary canine impaction: a re-
view. Am J Orthod Dentofacial Orthop 2015;148:557-67.
23. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposi-
tion, associated dental anomalies and genetic basis. Angle Orthod
1993;63:99-109; discussion 110.
24. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is ge-
netic and related to congenital absence of teeth. J Dent Res 1996;
75:1742-6.
Chaushu et al
25. Becker A, Sharabi S, Chaushu S. Maxillary tooth size variation in
dentitions with palatal canine displacement. Eur J Orthod 2002;
24:313-8.
26. Nagpal A, Pai KM, Sharma G. Palatal and labially impacted maxil-
lary canine-associated dental anomalies: a comparative study. J
Contemp Dent Pract 2009;10:67-74.
27. Yan B, Sun Z, Fields H, Wang L, Luo L. Etiologic factors for buccal
and palatal maxillary canine impaction: a perspective based on
cone-beam computed tomography analyses. Am J Orthod Dento-
facial Orthop 2013;143:527-34.
28. Light N, Chaushu S, Major PW, Flores-Mir C. 3D analysis of maxil-
lary incisor root inclinations in cases of unilateral maxillary canine
impaction. Eur J Orthod 2022;44:396-403.
29. Dekel E, Nucci L, Weill T, Flores-Mir C, Becker A, Perillo L, et al.
Impaction of maxillary canines and its effect on the position of adja-
cent teeth and canine development: a cone-beam computed tomog-
raphy study. Am J Orthod Dentofacial Orthop 2021;159:e135-47.
30. Hettiarachchi PV, Olive RJ, Monsour P. Morphology of palatally
impacted canines: a case-controlled cone-beam volumetric tomog-
raphy study. Am J Orthod Dentofacial Orthop 2017;151:357-62.
31. Alqerban A, Jacobs R, Fieuws S, Willems G. Comparison of two
cone beam computed tomographic systems versus panoramic im-
aging for localization of impacted maxillary canines and detection
of root resorption. Eur J Orthod 2011;33:93-102.
32. Lai CS, Bornstein MM, Mock L, Heuberger BM, Dietrich T,
Katsaros C. Impacted maxillary canines and root resorptions of
neighbouring teeth: a radiographic analysis using cone-beam
computed tomography. Eur J Orthod 2013;35:529-38.
33. Peck S, Peck L. Classification of maxillary tooth transpositions. Am
J Orthod Dentofacial Orthop 1995;107:505-17.
34. Shapira Y, Kuftinec MM. Early diagnosis and interception of poten-
tial maxillary canine impaction. J Am Dent Assoc 1998;129:1450-4.
35. Becker A, Chaushu G, Chaushu S. Analysis of failure in the treat-
ment of impacted maxillary canines. Am J Orthod Dentofacial Or-
thop 2010;137:743-54.
36. Chaushu S, Chaushu G, Becker A. The use of panoramic radio-
graphs to localize displaced maxillary canines. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1999;88:511-6.
American Journal of Orthodontics and Dentofacial Orthopedics
699
37. Clark CA. A Method of ascertaining the Relative Position of uner-
upted teeth by means of Film Radiographs. Proc R Soc Med 1910;
3:87-90.
38. Jacobs SG. Localisation of the unerupted maxillary canine. Aust
Orthod J 1986;9:311-6.
39. Jacobs SG. Localisation of the unerupted maxillary canine: further
observations. Aust Orthod J 1988;10:247-51.
40. Liuk IW, Olive RJ, Griffin M, Monsour P. Associations between
palatally displaced canines and maxillary lateral incisors. Am J Or-
thod Dentofacial Orthop 2013;143:622-32.
41. Baratieri C, Canongia AC, Bolognese AM. Relationship between
maxillary canine intra-alveolar position and maxillary incisor
angulation: a cone beam computed tomography study. Braz
Dent J 2011;22:146-50.
42. L€udicke G, Harzer W, Tausche E. Incisor inclination–risk factor for
palatally-impacted canines. J Orofac Orthop 2008;69(5):357-64.
43. Kanavakis G, Curran KM, Wiseman KC, Barone NP, Finkelman MD,
Srinivasan S, et al. Evaluation of crown-root angulation of lateral
incisors adjacent to palatally impacted canines. Prog Orthod 2015;
16:4.
44. Broadbent BH. Ontogenic development of occlusion. Angle Orthod
1941;11:223-41.
45. Leonardi R, Muraglie S, Crimi S, Pirroni M, Musumeci G, Perrotta R.
Morphology of palatally displaced canines and adjacent teeth, a 3-
D evaluation from cone-beam computed tomographic images.
BMC Oral Health 2018;18:156.
46. Langberg BJ, Peck S. Tooth-size reduction associated with occur-
rence of palatal displacement of canines. Angle Orthod 2000;70:
126-8.
47. Becker A, Smith P, Behar R. The incidence of anomalous maxillary
lateral incisors in relation to palatally-displaced cuspids. Angle Or-
thod 1981;51:24-9.
48. Alemam AA, Abu Alhaija ES, Mortaja K, AlTawachi A. Incisor root
resorption associated with palatally displaced maxillary canines:
Analysis and prediction using discriminant function analysis. Am
J Orthod Dentofacial Orthop 2020;157:80-90.
49. Chaushu S, Sharabi S, Becker A. Tooth size in dentitions with
buccal canine ectopia. Eur J Orthod 2003;25:485-91.
May 2023  Vol 163  Issue 5