Yamamoto,

Asian J Oral Maxillofac Ohta,

Surg Tsuda, et al
2003;15:31-37.
CLINICAL OBSERVATIONS

A New Classification of Impacted Canines and Second

Premolars Using Orthopantomography

Gaku Yamamoto,1 Yoshiyuki Ohta,2 Yoshizou Tsuda,3 Akio Tanaka,3 Masanori Nishikawa,1 Hirofumi Inoda1
1
Department of Oral and Maxillofacial Surgery, Shiga University of Medical Science, Shiga, Japan
2
Ohta Orthodontic Clinic, Shiga, Japan
3
Department of Oral and Maxillofacial Surgery, Shiga Medical Center for Adult Diseases, Shiga, Japan

Abstract
Objective: To establish a simple classification of impacted canines and second premolars.
Patients and Methods: Impacted canines and second premolars were examined according to the inclination
of the tooth axis to the occlusal plane as determined by orthopantomograms.
Results: Seventy impacted canines in 65 patients and 40 impacted second premolars in 37 patients were
included in the study. Based on the angle of inclination of the tooth axis to the occlusal plane on the
orthopantomogram, impacted maxillary and mandibular canines and second premolars were classified into
7 types.
Conclusion: This classification should be advantageous for dental practice and useful for documentation
and correlation with treatment outcomes.

Key Words: Tooth, impacted, Cuspid, Bicuspid, Classification, Radiography, panoramic

Introduction presence of impacted canines or second premolars

Permanent canines and premolars are second only
to the third molars in frequency of impaction, and
their presence greatly affects the options for treat-
ment planning both for oral and maxillofacial surgery
and orthodontics. Although there are many variations
of impaction, there is still no classification system
that is widely used at present.
In this study, the impaction of canines and second
premolars were classified according to the angle
between the tooth axis and the occlusal plane as
determined by orthopantomograms.
Patients and Methods
Patients with impacted canines or second premolars
treated in the Department of Oral and Maxillofacial
Surgery at the Shiga University of Medical Science
in Japan and a private practice between April 1997
and May 1988 were selected for the study. The
Correspondence:
Gaku Yamamoto, Department of Oral and Maxillofacial Surgery,
Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan.
Tel: (81 77) 548 2352, Fax: (81 77) 544 0957
E-mail: gaku@belle.shiga-med.ac.jp
was revealed by orthopantomography at initial
examination, and the chief complaint was either
disturbances of eruption of the canines and second
premolars or aesthetics in these regions.
Tooth impaction is defined as a tooth remaining
in the jawbone without erupting, or as a tooth being
completely or incompletely embedded in the jawbone
or under the mucosa for more than 2 years after the
normal eruption period.1,2 However, it is often difficult
to determine whether an unerupted canine is truly
impacted or eruption is only delayed, especially in
young patients aged between 11 and 15 years.
Therefore, in this study, only canines that were not
expected to erupt in the future such as those causing
resorption in the root of the lateral incisor, inverted
canines, and displaced canines were included.
There were 65 patients with 70 impacted canines
and 37 patients with 40 impacted second premolars.
For the patients with impacted canines (21 men and
44 women), the ages ranged from 12 to 45 years,
with approximately half the patients presenting aged

Asian J Oral Maxillofac Surg Vol 15, No 1, 2003 31

New Classification of Impacted Canines and Second Premolars

Age (years) Number of impacted teeth (%) Results

11 - 15 7 (10.0) Impacted Canines
16 - 20 34 (48.6) Impacted canines were classified as follows
21 - 30 15 (21.4) (Figure 1):
31 - 40 7 (10.0)
• type I — vertically impacted canines, with the tooth
41 - 50 7 (10.0)
axis being almost perpendicular to the occlusal
Table 1. Age distribution of patients with impacted canines.
plane, and located between the lateral incisor and
Age (years) Number of impacted teeth (%) first premolar. A tooth situated in close relation to
11 - 15 2 (5.0) the lateral incisor is also included in this classifi-
16 - 20 12 (30.0) cation. In such cases, the root of the lateral incisor
21 - 30 18 (45.0) may be resorbed, and space for eruption may not be
31 - 40 5 (12.5) secured, thus preventing eruption in the future
41 - 50 2 (5.0) • type II — impacted canines inclined mesially
> 50 1 (2.5) against the occlusal plane
Total 40 (100) • type III — impacted canines inclined distally
Table 2. Age distribution of patients with impacted second against the occlusal plane
premolars.
• type IV — horizontally impacted canines with the
between 16 and 20 years (Table 1). Sixty five of the crown directed mesially
70 impacted canines were in the maxilla (right side, • type V — horizontally impacted canines with the
39; left side, 26; bilateral, 5 ) and 5 were in the crown directed distally
mandible (right side, 3; left side, 2; bilateral, 0). • type VI — inversely impacted canines
• type VII — labio-lingual (palatal) impaction and
For impacted second premolars (21 men and 16 ectopic impaction. Impacted canines transposed in
women), the ages ranged from 12 to 53 years, with the arch resulting in a different order of teeth, for
the majority presenting between the ages 16 and 30 example, 132, 231, 132, 231, were also included in
years (Table 2). Thirty two of 40 impacted premolars this category.
were found in the maxilla (right side, 19; left side,
13; bilateral, 3) and 8 in the mandible (right side, 3; Of these 7 types, type I was associated with the
left side, 5; bilateral, 0). greatest number of teeth in this study (28 teeth,
40.4%). The number of teeth in the other categories
The angle between the tooth axis and the occlusal were as follows: type II (24 teeth, 34.3%), type IV (8
plane was estimated using orthopantomograms, and teeth, 11.5%), type VI (5 teeth, 7.1%), type VII (3
impacted canines and second premolars were teeth, 4.3%), and types III and V (1 tooth each, 1.4%)
classified according to this estimated angle. [Table 3].

Type I II III IV V VI VII

3 as a standard
3

State of impaction

2 4 2 4 2 4 2 4 2 4 3 4 1 2 3 4
Mesial Distal M D M D M D M D M D M D M D

Figure 1. Classification of impacted canines.

32 Asian J Oral Maxillofac Surg Vol 15, No 1, 2003

 Yamamoto, Ohta, Tsuda, et al

Type of impaction Number of impacted teeth (%) Type of impaction Number of impacted teeth (%)
I 28 (40.0) I 17 (42.5)
II 24 (34.3) II 8 (20.0)
III 1 (1.4) III 6 (15.0)
IV 8 (11.5) IV 4 (10.0)
V 1 (1.4) V 2 (5.0)
VI 5 (7.1) VI 1 (2.5)
VII 3 (4.3) VII 2 (5.0)
Total 70 (100) Total 40 (100)
Table 3. Distribution of impacted canines based on the type of Table 4. Distribution of impacted second premolars based on the
impaction. type of impaction.

Impacted Second Premolars abnormally located (displaced) second premolars.

Impacted second premolars were classified as follows
(Figure 2):
• type I — vertically impacted second premolars
located between the first premolars and first molar
with the tooth axis almost perpendicular to the
occlusal plane with the canine inclined distally or
the first molar inclined mesially
• type II — canines located in a lower portion than
type I teeth with the second premolar in close
relation to the apex of the first premolar
• type III — impacted second premolars inclined
mesially or distally with the second deciduous
molar remaining in the dental arch
• type IV — horizontally impacted second premolars
with the tooth axis almost parallel to the occlusal
plane with the crown directed mesially
• type V — horizontally impacted second premolars
with the tooth axis almost parallel to the occlusal
plane with the crown directed distally
• type VI — inversely impacted second premolars
• type VII — second premolars with the axis inclined
in the bucco-lingual (palatal) direction or
Misplaced premolars transposed in the arch re-
sulting in a different order of teeth, for example,
5467, 7645, 5467, 7645, were also included in this
category.
Of these 7 types, the highest number of teeth in
this study, 17 (42.4%) were included in the type I
category. The number of teeth in the other categories
decreased as follows: type II (8 teeth, 20.0%), type
III (6 teeth, 15.0%), type IV (4 teeth, 10.0%), type V
and type VII (2 teeth each, 5.0%), and type VI (1
tooth, 2.5%) [Table 4].
Discussion
Impacted Canines
The upper canines are only second to the upper
and lower third molars in frequency of impaction.3
This frequency is primarily caused by the lack of
space for eruption because the canines erupt later
than the adjacent teeth. The tooth germ of the upper
canine is first formed at 24 weeks of gestation and
remains embedded in the maxilla for approximately

Type I II III IV V VI VII

5 as a standard

State of impaction

Mesial Distal

Figure 2. Classification of impacted second premolars.

Asian J Oral Maxillofac Surg Vol 15, No 1, 2003 33

New Classification of Impacted Canines and Second Premolars
12 years. Therefore, the tooth erupts later than
any other permanent tooth at the age of 11 to 12
years. As a consequence of this late eruption, the
surface of the bone where the tooth germ of the
upper canine is formed is subjected to various
unfavourable influences for a prolonged period
including pressure from surrounding anatomical
structures such as the nasal cavity, orbital cavity,
and maxillary sinus.4
In contrast to the upper canine, the germ of the
upper lateral incisor is formed at 5 to 5.5 months of
gestation (slightly earlier than that of the upper
canine) and erupts at the age of 8 to 9 years, which is
also earlier than the upper canine. The germ of the
first premolar is formed at birth, which is much later
than that of the upper canine, and eruption occurs at
the age of 10 to 11 years, which is earlier than for the
canine. Therefore, space needs to be secured between
the lateral incisor and first premolar, both of which
have already erupted and are involved in occlusion,
for the canine to erupt in the normal position.4,5
Difficulty in securing this space is the greatest cause
of impacted canines.
The deep positioning of the germ of the canine
also contributes to the impaction of canines. Impac-
tion of teeth that move only a short distance before
eruption is less common as illustrated by the first
molar, whose germ is formed closest of all the teeth
to the occlusal plane, and which is rarely impacted.5
Conversely, the germ of the canine is formed deep in
Normal eruption
Normal located tooth germ
Lack of eruption space
Mesial inclination and rotation
Inclination and rotation
of the tooth germ
Distal inclination and rotation
Formation of the germ
of the upper canine
Inverted teeth
Tooth germ located in the palatal side
Displacement and palato-labial rotation of the tooth germ
Figure 3. Relationship between the location of the germ of the uper canine and the state of impaction.
34
the jawbone and has the greatest distance of all teeth to
the occlusal plane. It is thought that even slight germ
displacement or a rotation that causes variation from
the normal eruption pattern will result in various types
of impaction, as shown in Figure 3.
Eruption of the upper canine is affected by the
lateral incisor. The upper canine normally runs along
the root of the lateral incisor with the forming crown
slightly inclined mesially at the disto-labial side of
the root of the incisor. Based on 70 cases presenting
as abnormal eruptions of the canine into the palatal
side where the root of the lateral incisor was, on
average, much shorter than in 106 cases presenting
with normal eruption,6 the lateral incisor is thought
to help guide the canine along its eruption path.
In 33 of 40 lateral incisors adjacent to impacted
canines (82%), the root length was two-thirds the
normal root length owing to root resorption.7 This
indicates the importance of the lateral incisor in
canine tooth eruption, given that the canine erupts
along the root of the lateral incisor while inclined.
The canine is apt to become impacted because, when
it erupts, the tooth replaces a deciduous tooth that is
narrower than the canine, and has to break through
the hard palate and palatal mucosa.4
In this study, 23 of 70 impacted canines were
found in men and 47 in women, suggesting that
canine impaction is more common among women
than men. This gender difference may be attributable
Type I impaction
Labial displacement
Crowding of central and lateral incisors
Type II impaction crowding and root resorption of central
and lateral incisors
Type IV impaction when the germ is directed horizontally
Type III impaction
Curved roots of premolars
Type IV impaction when the germ is directed horizontally
Type VI impaction
Impaction in the paatal side often seen as Type I or
Type II root resorption of incisors in many cases
Type VII impaction
Asian J Oral Maxillofac Surg Vol 15, No 1, 2003

to the fact that the skull, maxilla, and mandible are
smaller in women than in men.5 Although there is no
literature describing the size of the jawbone in persons
with impacted teeth, it is believed that there are
differences in the size of the jawbones between
persons with or without impacted teeth.
The characteristics of each type of impaction in
our classification are as follows:
• type I — when the tooth is impacted on the labial
side, it may erupt later to become a low and labially-
displaced tooth. If sufficient space is secured,
especially in young patients, natural eruption will
probably be possible. When the tooth is impacted
on the palatal side, surgical treatment such as
fenestration and traction is more difficult than for
teeth impacted on the labial side.
• type II — rotation of the tooth is rare, but the root
of the lateral incisor is often found to be resorbed.
When the degree of resorption is high, the lateral
incisor needs to be extracted before inducing
eruption of the canine. When the root of the lateral
incisor is free from resorption, the crown of the
lateral incisor needs be distally inclined before
inducing eruption of the canine. The lateral incisor
may be extruded in some instances involving
impaction of the upper canines.
• type III — the presence of an impacted canine may
coincide with the root formation of the premolars,
resulting in curved or short premolar roots. Since
the germ of the canine is formed slightly anteriorly,
there are more instances of type II than of type III
impaction.
• type IV — in the maxilla, the tooth is often located
horizontally, with the crown directed mesially.
Since some lower canines move to the contralateral
side beyond the midline, long-term follow-up is
necessary.8
• type V — many impacted teeth are located in the
anterior part of the lower wall of the maxillary sinus
with the crown directed distally. As in type VI
impaction, some cases have previously been
reported in which the impacted tooth had migrated
within the jawbone.9 Thus, long-term follow-up is
necessary.
• type VI — inversely impacted teeth are located in
the anterior wall of the maxillary sinus with the
crown directed toward the medial angle of the eye
Asian J Oral Maxillofac Surg Vol 15, No 1, 2003
Yamamoto, Ohta, Tsuda, et al
in the nasal process of the maxilla. Eruption of the
tooth in the lower eyelid has also been reported.10
Usually, the tooth can be left untreated, but when
the tooth erupts into the maxillary sinus or nasal
cavity, infection may occur and tooth extraction is
indicated.
• type VII — labio-lingual (palatal) impaction or
abnormally located (displaced, misplaced) im-
paction is relatively rare. In misplaced cases, it
is difficult to change the location of the canine and
lateral incisor by orthodontic treatment. Therefore,
eruption is often induced without changing the
location of these teeth, which remain misplaced in
the dental arch. From an embryological perspective,
few premolars replace the adjacent canine. Early
treatment is recommended when rotation of the
germ is needed before inducing eruption.
Impacted Second Premolars
It is well established that maintaining the length of
the deciduous dental arch is crucial for completion
of healthy permanent dental arch in the future. When
the deciduous second molar is lost at an early age,
because all erupting teeth exert force, the erupting
first molar located posterior to the deciduous second
molar will be inclined. However, the deciduous first
molar will be distally inclined.11 This inclination is
attributable to the loss of the deciduous second molar
located distal to this tooth as well as labial or buccal
force from the buccinator muscle. Thus, ample space
cannot be secured for eruption of the second premolar,
causing impaction of this tooth. When the deciduous
second molar is severely decayed or when incomplete
eruption of the deciduous second molar causes it to
remain partially submerged, the first molar will
similarly be inclined, and the space for the eruption
of the second premolar is lost, causing impaction of
this tooth. Thus, when the deciduous second molar
is lost at an early age or is retained for a prolonged
period, it greatly influences impaction of the second
premolar.
For all of the aforementioned reasons, the
deciduous second molar is an important factor to be
considered in relation to the impaction of the second
premolar. In this study, impaction of the second
premolar was classified into 7 types based on the
condition of the deciduous second molar as shown
35
New Classification of Impacted Canines and Second Premolars
in Figure 2. The characteristics of each type are as
follows:
• type I — due to the early loss or incomplete eruption
of the deciduous second molar, the first premolar
is often inclined, resulting in a lack of space for
eruption of the second premolar. Since the mandible
contains hard cortical bone, eruption of the second
premolar is often prevented, causing incomplete
impaction with curved roots.
• type II — this type is often found in the maxilla.
Due to a lack of space, the second premolar is often
located near the apex of the first premolar,
preventing root formation of the first premolar.
There is little space for eruption.
• type III — space for eruption is sufficient, but
impaction of the second premolar is considered
secondary to an abnormal course of eruption
resulting from the presence of the deciduous second
molar. Thus, the second premolar is impacted while
inclined mesially or distally. The first molar may
be inclined because the deciduous second molar is
retained for a prolonged period, shows severe decay
in the crown, or is submerged.
• types IV and V — these are extremely rare. A
considerable number of teeth are, however,
classified into the intermediate type between types
III and IV.
• type VI — this type involves the maxilla more
frequently than the mandible. When surgical
treatment is needed, attention to the maxillary sinus
and the roots of the adjacent teeth as in types IV
and V is required.
• type VII — this type is extremely rare. These
authors have encountered 1 case of labio-lingual
impaction. Induced eruption may be feasible
depending on patient age and local conditions.
The advantages of this classification system
for impacted canines and second premolars are that
the classification can be performed using ortho-
pantomography; impacted teeth can be clearly
classified using the estimated angle between the tooth
axis and the occlusal plane to evaluate the state of
impaction; classification is possible in any part of
the jaw (upper jaw, lower jaw, left side, right side);
and each type has its own characteristics, and the
treatment plan can be formed on the basis of these
characteristics.
36
The disadvantages of this classification are that
rotation of the impacted tooth is not considered; more
than 2 impacted teeth, including involvement of
adjacent teeth in the same area, cannot be classified;
and, since this classification is only based on exam-
ination by orthopantomography, the labio (bucco)-
lingual (palatal) relationship can not be examined.
Thus, further macroscopic inspection, palpation, and
other projections of radiography should be added
to allow for a comprehensive evaluation prior to
treatment.
In this study, a new classification was developed
according to the angle between the axis of the
impacted teeth and the occlusal plane as determined
by orthopantomograms, based on 70 impacted
canines and 40 impacted second premolars. As
a result, impacted canines and second premolars
were classified into 7 types. Each type has its own
characteristics, which are useful in forming treatment
plans. Utilisation of this classification is appropriate
in general dentistry, oral and maxillofacial surgery,
orthodontics, pedodontics, and radiology, and may
prove helpful for correlating the degree of impaction
with treatment outcomes.
Acknowledgement
The authors thank Professor Emeritus Yoshikuni Ohta
for reviewing the manuscript.
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