SHORT COMMUNICATION

Eruption of the maxillary canines in relation to

skeletal maturity
Tiziano Baccetti,a Lorenzo Franchi,a Simona De Lisa,b and Veronica Giuntinib
Florence, Italy

Introduction: Our aim in this study was to assess the relationship between the eruption of the permanent
maxillary canines and skeletal maturity in subjects with different skeletal relationships in the sagittal and
vertical planes. Methods: A sample of 152 subjects (63 boys, 89 girls) with erupting permanent maxillary
canines was analyzed. On the lateral cephalograms, the stage of cervical vertebral maturation was assessed.
Then the subjects were divided into prepeak (before the pubertal growth spurt, cervical stage [CS]1 and
CS2), peak (during the pubertal growth spurt, CS3 and CS4), and postpeak (after the pubertal growth spurt,
CS5 and CS6) groups. Skeletal relationships in the sagittal and vertical planes were evaluated, and
relationships to timing of canine eruption were tested statistically. Results: The prepeak group comprised 86
subjects, the peak group 66 subjects, and the postpeak group 0 subjects. The differences in prevalence rates
between either the prepeak or peak groups and the postpeak group were statistically significant (P ⬍0.001).
The prevalence rate for hyperdivergent subjects showing eruption of the permanent maxillary canine in the
prepeak group (37.2%) was significantly higher than in the reference orthodontic population (21%).
Conclusions: The eruption of the permanent maxillary canine can occur at any stage in skeletal maturation
before the end the pubertal growth spurt (CS1-CS4), with hyperdivergent subjects more frequently having
prepubertal canine eruption. (Am J Orthod Dentofacial Orthop 2008;133:748-51)

T
he frequency of impaction of the maxillary
canines ranges from 0.8%1 to 3.6%.2 Lack of
eruption of these teeth often requires a com-
bined surgical and orthodontic therapeutic approach,
and it may be associated with unfavorable sequelae
such as resorption of the roots of the adjacent lateral
incisors.3
The literature indicates average ages of about 12
years for girls and 13 for boys for maxillary canine
emergence.4,5 Individual variability of eruption is great,
and, more importantly, there is a weak correlation
between chronologic age and biologic processes related
to tooth development and eruption.6,7 Therefore, it is
difficult to define canine delayed eruption or impaction
on the basis of the subject’s age or dentition stage.
Biologic indicators of skeletal maturity are avail-
able as alternative methods to chronologic age for a
more reliable assessment of dentoskeletal developmen-
tal events in growing subjects. Hägg and Taranger7
reported that all canines and premolars are usually
From the Department of Orthodontics, University of Florence, Florence, Italy.
a
Assistant professor; Thomas M. Graber Visiting Scholar, Department of
Orthodontics and Pediatric Dentistry, School of Dentistry, University of
Michigan, Ann Arbor.
b
Lecturer.
Reprint requests to: Lorenzo Franchi, Università degli Studi di Firenze, Via del
Ponte di Mezzo, 46-48, 50127, Firenze, Italy; e-mail, l.franchi@odonto.unifi.it.
Submitted, July 2007; revised and accepted, October 2007.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.10.031
748
erupted by the end of the pubertal growth spurt as
assessed with the hand-wrist method, thus confirming
previous observations by Björk and Helm.6 Recently,
evaluation with the cervical vertebral maturation
(CVM) method has gained acceptance for the appraisal
of skeletal maturity in orthodontic patients.8 Our aim in
this study was to assess the relationship between the
eruption of the permanent maxillary canines and the
stages of CVM to give clinicians an alternative method
for the definition of the expected time of canine
eruption in the late mixed dentition.
MATERIAL AND METHODS
A sample of 152 subjects (63 boys, 89 girls) at the
Department of Orthodontics of the University of Flo-
rence with at least 1 permanent maxillary canine during
the final phase of intraoral eruption was analyzed. This
phase of eruption was defined as the emergence of the
canine from the initial appearance of the tip of the cusp
in the dental arch (assessed on both dental casts and
intraoral photographs) to a 1-mm distance of the tip of
the cusp from the maxillary occlusal plane (traced on the
panoramic radiograph).9 Lateral cephalograms taken at
the same time as the dental casts, intraoral photographs,
and panoramic radiographs were available for all sub-
jects. Other inclusionary criteria were white ancestry,
no previous orthodontic treatment, no multiple tooth
agenesis, no craniofacial anomalies, no traumatic inju-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 5
Fig 1. Diagrammatic representation of the 6 stages of CVM. CS1 and CS2 are prepubertal stages.
CS3 and CS4 comprise the pubertal growth spurt. CS5 and CS6 are postpubertal stages. The
assessment of the stages is based on the visual analysis of the cervical vertebrae on lateral
cephalograms. Reprinted from Baccetti et al,8 with permission from Elsevier.
ries or massive caries of the dentition, and no patho-
logic obstacles to the eruption pathway of the maxillary
canines (eg, odontomas, cysts, supernumeraries).
On each lateral cephalogram, the CVM stage was
assessed according to the method of Baccetti et al (Fig
1).8 Two examiners (T.B. and L.F.) evaluated the
cervical stage (CS) independently and agreed on the
final categorization. Then the subjects were divided
into prepeak (CS1 and CS2), peak (CS3 and CS4), and
postpeak (CS5 and CS6) groups.
Skeletal relationships in the sagittal and vertical
planes were evaluated with cephalometric analysis that
included the ANB angle and the SN/mandibular plane
(SN/MP) angle, respectively. The cephalograms were
hand traced by 1 investigator (S.D.L.) and verified for
landmark location by a second (L.F.). Cephalometric
software (Viewbox, version 3.0, dHAL Software, Ki-
fissia, Greece) was used for measurements on digitized
cephalograms. The error of the method was smaller
than 1° for both measurements. Subjects were classified
as hyperdivergent when the SN/MP angle was greater
than 39°, normodivergent when the SN/MP angle was
between 29° and 39°, and hypodivergent when the
SN/MP angle was smaller than 29°.10 They were also
classified as skeletal Class II when the ANB angle was
greater than 5°, skeletal Class I when the ANB angle
was between 1° and 5°, and skeletal Class III when the
ANB angle was smaller than 1°.10
Statistical analysis
The distribution of the CVM stages in the sample
showing eruption of the maxillary canines was evalu-
ated. A statistical analysis of prevalence rates (z test on
proportions) tested significant differences in the prev-
Baccetti et al 749
alence of canine eruption in the 3 groups according to
skeletal maturation (prepeak, peak, postpeak). The
prevalence rates for the groups according to vertical
(hyperdivergent and hypodivergent) or sagittal (Class II
and Class III) skeletal relationships were evaluated in
the 3 CVM groups and compared with reference control
prevalence rates with chi-square tests (SigmaStat 3.1,
Systat Software, Point Richmond, Calif).11
RESULTS
The ages of the 152 subjects in the final phase of
canine eruption ranged from 8 years 8 months to 14
years. The distribution of the CVM stages was as
follows: CS1, 42 (27.7%); CS2, 44 (28.9%); CS3, 57
(37.5%); CS4, 9 (5.9%); CS5, 0; and CS6, 0. When
combined in 3 groups, the prepeak group comprised 86
subjects (56.6%), the peak group had 66 subjects
(43.4%), and the postpeak group had no subjects. The
differences in prevalence between either the prepeak or
the peak groups and the postpeak group were obviously
significant (P ⬍0.001), whereas the comparison be-
tween prepeak and peak groups was not significant (z ⫽
1.45; P ⫽ 0.147).
The prevalence rate for hyperdivergent subjects
showing eruption of the permanent maxillary canine in
the prepeak group (37.2%) was significantly higher than
in the reference orthodontic population (21%) (P ⬍0.001)
(Table). No significant differences in the timing of canine
eruption were found in relation to hypodivergent skeletal
relationships or sagittal skeletal relationships (Table).
DISCUSSION
We evaluated the physiologic eruption of the max-
illary permanent canine in relation to the skeletal
750 Baccetti et al American Journal of Orthodontics and Dentofacial Orthopedics
May 2008

Table. Prevalence rates and statistical comparisons (chi-squared test) on subgroups according to vertical or sagittal
skeletal relationships
Prevalence Prevalence rate Reference prevalence rate* Significance P value

Pre-peak (CS1-CS2) n ⫽ 86
Hyperdivergent 32/86 37.2% 21% 0.0009
Hypodivergent 32/86 37.2% 33% 0.541
Peak (CS3-CS4) n ⫽ 66
Hyperdivergent 20/66 30.3% 21% 0.104
Hypodivergent 25/66 37.9% 33% 0.533
Pre-peak (CS1-CS2) n ⫽ 86
Class II 27/86 31.4% 32% 0.908
Class III 5/86 5.8% 10% 0.284
Peak (CS3-CS4) n ⫽ 66
Class II 16/66 24.2% 32% 0.239
Class III 9/66 13.6% 10% 0.463

*Data from Sacerdoti et al.11

Fig 2. The permanent maxillary canine during the final phase of eruption in a subject aged 12 years
9 months: A, intraoral photograph; B, panoramic x-ray illustrating the distance from the tip of the
erupting canine and the maxillary occlusal plane; C, lateral cephalogram showing CS3.

maturity evaluated with the CVM method (Fig 1).8 We
confirmed that there is great interindividual variability
with regard to the age of emergence of the canine.1,4,5
According to these results, the permanent maxillary
canine erupts most frequently during the prepubertal
stages of skeletal development. In 56.6% of patients,
the canine erupts in the dental arch at least 1 year before
the pubertal growth spurt. In the remaining patients,
physiologic eruption of the tooth can be expected to
occur during the year of the growth spurt or the next
year (Fig 2). We found no subject with physiologic
eruption of the permanent maxillary canine during the
postpubertal period (CS5 or CS6). Similar outcomes
were found by Hägg and Taranger,7 who reported that
the eruption of the permanent canines and the premo-
lars had been attained in all subjects from a large group
of Swedish adolescents by the late pubertal growth
spurt as assessed by hand-wrist radiographs. Consider-
ing these data and the paucity of patients having
physiologic eruption of the canine at CS4 (5.9%) in our
study, it can be derived that the lack of eruption of the
permanent maxillary canine and a postpubertal stage
(CS5 and CS6) indicates delayed eruption of the
canine. At this time, canine impaction can be suspected
and further investigation implemented to arrive at a
definitive diagnosis. The analysis of skeletal maturity
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 5
can assist in the diagnosis of tooth eruption distur-
bances especially when the bilateral intraosseous posi-
tion of the maxillary canines is associated with gener-
alized retardation of tooth emergence and also in
patients with retarded eruption of 1 maxillary canine
associated with the early emergence of the contralateral
one. Likewise, our findings can be helpful for the
determination of the expected appearance in the dental
arch of displaced maxillary canines after interceptive
procedures to improve the rate of successful eruption of
these teeth.9,12,13
When timing of canine eruption was analyzed in
relation to vertical skeletal relationships, a significant
association was found between hyperdivergency (SN/MP
angle greater than 39°) and prepubertal eruption of the
permanent maxillary canine. Janson et al14 described
similar findings and reported a tendency for ad-
vanced dental emergence in skeletal open-bite sub-
jects when compared with skeletal deepbite subjects.
On the other hand, we did not confirm the observations
of Suda et al,15 who found delayed tooth formation and
eruption in skeletal Class III subjects compared with
Class II subjects.
CONCLUSIONS
1. Eruption of the permanent maxillary canine can
occur at any stage in skeletal maturation before the
end the pubertal growth spurt (CS1-CS4). A post-
pubertal stage (CS5 or CS6) without an erupted
maxillary canine indicates delayed canine eruption
and suggests canine impaction.
2. Eruption of the permanent maxillary canine occurs
more frequently in the prepubertal stages of skeletal
development in subjects with increased vertical
skeletal relationships.
Baccetti et al 751
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