European Journal of Orthodontics, 2023, XX, 1–11

https://doi.org/10.1093/ejo/cjad014
Randomized Controlled Trial (RCT)

Early prevention of maxillary canine impaction: a

randomized clinical trial
Guy Willems1, Charlotte Butaye1, , Margot Raes1, Chen Zong1, Giacomo Begnoni1 and
Maria Cadenas de Llano-Pérula1,
Department of Oral Health Sciences-Orthodontics, KU Leuven and Dentistry, University Hospitals Leuven, Leuven, Belgium
1

Correspondence to: Guy Willems, Department of Oral Health Sciences—Orthodontics, KU Leuven University and Service of Dentistry, University Hospitals
Leuven, Kapucijnenvoer 7, blok A, bus 7001, 3000 Leuven, Belgium. E-mail: guy.willems@uzleuven.be

Summary
Objectives: To investigate the effect of three interceptive measures (slow maxillary expansion (SME) with removable plates (1), extraction of
both upper deciduous canines (DC) (2) and no intervention (3)) on maxillary canine (MC) position in patients with early mixed dentition (EMD) and
lack of upper arch space. These three groups were additionally compared to a control group (4) with adequate upper arch space.
Null hypothesis: None of the studied strategies outperforms the others regarding improvement of MC position.
Trial design: Four-arm parallel group prospective randomized controlled trial.
Participants: Patients in EMD with at least one impacted MC, non-resorbed DC, and no crossbite.
Interventions: Patients with a lack of space were randomly distributed to protocols (1), (2), and (3).
Primary objective: To assess the change in MC position after 18 months follow up.
Secondary objectives: To assess canine eruption and need for orthodontic intervention within 18–60 month follow up.
Outcome assessment: Five variables defined canine position: sector, canine-to-midline angle, canine-to-first-premolar angle, canine-cusp-to-
midline distance, and canine-cusp-to-occlusal-plane distance on two panoramic radiographs at 0 (T1) and 18 months (T2). Mean differences
between groups were compared with linear mixed models, corrected for age and sex.
Randomization: The patient allocation sequence was generated by an electronic randomization list.
Blinding: The operator taking the measurements was blinded to the groups.
Results: Seventy-six patients were included (142 canines, mean age 9.2 years, 60.5 per cent male, mean follow up 1.9 years), 19, 17, 14,
and 26 patients in groups 1–4, respectively. In absence of dental crossbite in patients with lack of space and impacted MC, SME improved
the canine sector (P = 0.040), compared to no intervention (P = 0.028). Canine-to-midline angle and canine-to-occlusal-plane distance sig-
nificantly decreased in all groups at T2. Extraction improved the canine-to-first-premolar angle at T2 more than other strategies in EMD (P =
0.015–0.000).
Conclusions: Early SME improves the canine sector and reduces the need for major orthodontic intervention in the long term. Taking a first
panoramic radiograph in EMD allows timely intervention in case of MC impaction.
Trial Registration Number: NCT05629312 (Clinical Trials.org). Trial status: follow up ongoing.

Introduction promoting the eruption of PDC as extracting the deciduous

Maxillary canine (MC) impaction, which occurs more often
unilaterally and in female patients, affects 1.7–4.7 per cent
of the population (1). Orthodontic interception of MC im-
paction in early mixed dentition (EMD) has been reported to
reduce the risk of root resorption of neighbouring teeth and
the need for surgical exposure of the impacted canines, as well
as to decrease orthodontic treatment time and complexity (2).
One of the most frequently used interceptive measures
is the extraction of deciduous teeth. Two randomized con-
trolled trials (RCTs) report higher eruption rates of palatally
displaced maxillary canines (PDC) in patients where de-
ciduous upper canines were extracted, compared to control
groups without intervention (3,4). Hadler-Olsen et al. found
the extraction of deciduous upper canines together with the
extraction of deciduous upper first molars to be as efficient in
canines (DC) only (5), while Alessandri Bonetti et al. found
the double extraction pattern to lead to better outcomes (6,7).
Benson et al. (8) performed a Cochrane review in 2021 up-
dating that of Parkin et al. in 2017 (9), concluding that the ex-
traction of deciduous upper canines in patients between 9 and
14 years old with PDC increases the proportion of erupted
PDC’s without surgical intervention. However, this review
could only include four studies (4–7) and states clearly that
the certainty of the evidence was low.
Benson et al. (8) also acknowledge in their systematic re-
view the publication of a new protocol trying to incorporate
interceptive interventions other than extraction of primary
teeth, such as widening or lengthening of the dental arch by
using ‘quad-helix, rapid maxillary expansion (RME), head-
gear, mini-implants, fixed orthodontic appliances or other

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please
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2 European Journal of Orthodontics, 2023
techniques’, but they were not able to include any RCTs
complying with their selection criteria. Although indeed not
strong, some evidence can be found in literature regarding the
use of different orthodontic appliances in patients with im-
pacted MCs. For instance, a cervical headgear together with
the extraction of upper DC has been reported to increase the
eruption rate of impacted canines (10,11). RME in EMD has
also been reported to lead to a 66 per cent increase in the
eruption rate of impacted MCs (12), and this increase would
go up to 86 per cent when RME and cervical headgear are
combined (13). Slow maxillary expansion (SME) is also ef-
fective in increasing the transversal maxillary dimension (14).
Caprioglio et al. retrospectively compared the effects of SME
with Quad-helix and Haas expander with a control group
without intervention after 12 months of treatment in a cohort
of 6- to 11-year-old patients, finding an improvement of the
canine-to-midline angle only with the Haas appliance (15).
SME can also be performed with removable expansion plates,
but, to the best of our knowledge, the effect of these appli-
ances on MC impaction has not yet been investigated (16).
Despite the fact that systematic implementation of early
interceptive measures has been reported to lead to lower
prevalence of impacted MCs (1), clinical trials comparing
the outcomes of different strategies on MC impaction in
EMD are scarce (16), which ultimately affects therapeutic
decision-making. Using interceptive measures to avoiding ex-
tensive orthodontic treatment in older subjects is cost-effective
and implies obvious advantages for the patient.
This RCT aims to study the effect of SME, deciduous upper
canine extraction and no intervention on the position of im-
pacted permanent upper canines in patients presenting EMD
and lack of space in the dental arch. In addition a control
group with adequate space in the dental arch was used for
comparison. The null hypothesis (none of the studied strat-
egies outperforms the others in terms of improvement of MC
position) will be tested.
Subjects and methods
Subject recruitment and eligibility criteria
The present study is a non-commercial, prospective RCT with
a parallel design. The study protocol was approved by the
ethical committee of University Hospitals Leuven and KU
Leuven University (registration number S59030) and has
been carried out in accordance with The Code of Ethics of
the World Medical Association (Declaration of Helsinki).
All patients presenting at the intake consultation of the
Department of Orthodontics of University Hospitals Leuven,
Belgium between September 2016 and January 2022, with
at least one maxillary permanent canine impaction were in-
vited to participate. Canine impaction was diagnosed based
on a panoramic radiograph, taken for standard evaluation
of dental development and associated pathology from the
age of 8 years old. An MC was considered to be impacted
when the canine-to-midline angle was ≥15° (17,18). Only im-
pacted MCs with incomplete root formation and with per-
sisting, non-resorbed DC were included. Since randomization
of treatment approaches would not be ethical in case of severe
canine impaction, which requires immediate intervention, the
sector where the canine cusp was positioned was taken as an
additional selection criterion besides canine-to-midline angle.
The sector was scored using the modification of the Ericson
and Kurol (19) method proposed by Raes et al. (20). Only
patients with canine cusps positioned in sectors ≤1 on pano-
ramic radiographs (canine cusp not beyond the distal half of
the lateral incisor’s root) were included in the study.
Exclusion criteria were presence of uni or bilateral pos-
terior dental crossbite, upper permanent canines showing root
malformation, ankylosis or fully erupted, evidence of root re-
sorption of adjacent teeth, previous orthodontic treatment,
craniofacial syndromes, systemic disease that would impede
orthodontic treatment/surgery and recent exposure to radio-
therapy. When large eruption follicles were seen on the per-
manent canines, extraction of the DC and marsupialization
of the eruption cyst constituted the standard approach, which
was also a reason for exclusion from this RCT. Before enrol-
ment, written informed consent was obtained from all parti-
cipants and their parents/guardians.
Group allocation and interventions
The study diagram can be found in Figure 1. Patients were
included at T1 (baseline) and subdivided into two groups de-
pending on the lack of space in the upper arch (crowding in
the upper arch either ≤ or > 2 mm, determined clinically).
Patients with lack of space were randomly attributed to three
treatment protocols: 1. SME using a removable appliance pre-
viously described (14), 2. extraction of both upper DC (to
prevent asymmetry and midline shifts) or 3. no intervention.
The latter constitutes an internal control group, indicative for
maxillary permanent canine eruption in case of lack of space
in the dental arch. Patients with adequate space in the upper
arch were considered as 4. an external control group, indi-
cative of ‘ideal’ dental occlusion, where no intervention was
performed and canine eruption was simply followed up. An
electronic randomization list, managed by one operator, was
used to generate the patient allocation sequence.
All patients were enrolled in a standard follow up protocol
requiring a recall visit every 6 months. If the canine had not
yet erupted at the 6 and 12 month visits, a long cone ap-
ical radiograph was taken for evaluation of canine position.
If necessary, an orthodontic intervention could be initiated
at any point, which led to exclusion of the patient from the
trial. 18 months after the start of follow up (T2), a new pano-
ramic radiograph was taken and the need for further ortho-
dontic treatment was re-evaluated. Eventually, canines either
erupted spontaneously or their eruption was facilitated with
further orthodontic treatment. Extraction of DC and/or de-
ciduous first molars, or a simple protrusion, mesialization or
distalization spring on a removable appliance were considered
as minor orthodontic interventions. Major orthodontic inter-
ventions consisted of extraction of bicuspids, orthodontic
transversal or sagittal expansion or even surgical exposure
when necessary.
Methods
Panoramic radiographs were taken with a VistaPano S appli-
ance (Dürr Dental, Bietigheim-Bissingen, Germany). Patients
were instructed to stand straight with their gaze focussed on
a point set on the wall in front of their eyes. A positioner was
placed on soft nasion in order to standardize head position
and avoid positioning errors.
The primary outcome measure was canine position. In
order to determine it, the following variables were assessed
on digital panoramic radiographs at T1 and T2 (Figure 1):
sector where the canine cusp was located, canine-to-midline
angle (3^ML), canine-to-first premolar angle (3^4), canine
G. Willems et al.
Figure 1 Study diagram.
cusp-to-midline distance (3c-ML) and canine cusp-to-occlusal
plane distance (3c-OP) (17,18,20). For the angular measure-
ments, the tooth axis was used. The maxillary dental midline
was determined by the anterior nasal spine and the middle
point between the two central incisors. In order to avoid per-
forming linear measurements on OPG, these were calibrated
by using a multiplication of the maxillary central incisor
width of the contralateral side, which was arbitrarily set at 10
(20,21). The distance of the canine cusp was measured per-
pendicular to the midline or the occlusal plane respectively.
3
The occlusal plane was defined as an horizontal tangent to the
incisal edge of the maxillary first permanent incisor and the
mesio-buccal cusp tip of the first permanent molar. Both dis-
tances were then interpreted in proportion to the width of the
central incisor (e.g. if the central incisor is 9 mm (considered
10) and 3c-ML is 18 mm, then 3c-ML is 20, or 2 times the
width of the central incisor). Canine position was determined
on Impax software, version 6.5 (Agfa, Mortsel, Belgium). All
measurements were taken once by the same observer (CB),
blinded to the interceptive technique used. Measurements
4 European Journal of Orthodontics, 2023

were taken after calibration on a preliminary training dataset,

3 vs. 4

0.966
0.217
0.122
0.110
previously published (20). Intra-operator reliability was not
formally evaluated.
Secondary measures were 1. the timing of canine eruption
2 vs. 4

0.238
0.157
0.157
0.052
and 2. the need for an additional intervention after the study
period.
Patient-reported outcomes (e.g. patient’s perception of his/
2 vs. 3

0.331
0.634
0.796
0.815
her own malocclusion) were not taken into consideration in
this RCT.
Pairwise comparisons (P values)

Statistical analysis
0.007*
1 vs. 4

0.535
0.071
0.058
Baseline characteristics were compared between groups using
the chi-squared test for categorical variables or the Kruskal–
Wallis test for continuous variables.
1 vs. 3

0.402
0.353
0.956
0.393

Linear mixed models were used for the analysis of canine

position, modelling a random intercept to account for re-
peated measurements (two teeth per patient and/or two time
1 vs. 2

0.716
1.000
0.849
0.516

points). Results are presented as estimated mean differences

with 95 per cent confidence intervals.
The change scores between T2 and T1 were obtained by
0.607
0.225
0.201
0.054

subtracting the outcome at T1 from that of T2. Therefore,

positive values mean ‘increase’ and negative values mean ‘de-
P

crease’ over time. Since sector is an ordinal variable where a

72/142 (50.7)
70/142 (43.3)

higher score represents a worse outcome, the change score

30/76 (39.5)
46/76 (60.5)

represents the number of levels of improvement (if negative)

8.7; 15.4
7.0; 13.2

1.0; 3.4

or worsening (if positive). For clinical improvement, 3^ML,

Total

11.0

3^4, and 3c-OP should decrease (negative change values)

1.9
9.2

while 3c-ML should increase (positive change values).

Binary long-term follow up (18–60 months) outcomes at
25/48 (52.1)
21/26 (80.8)
23/48 (47.9)
Control (4)

5/26 (19.2)

patient level were analysed using the Fisher exact test, pro-
8.9; 15.4
7.7; 13.2

1.0; 3.4

viding frequent occurrence of small (<5) cell counts. Analyses

11.6

at tooth level were performed using logistic regression with

2.0
9.7

F: Female; M: Male; NI: No intervention; R: Range; vs.: versus. *P-values <0.05 are considered significant.

estimation based on generalized estimating equations to

account for clustering of teeth within patients. Results are
No intervention (3)

presented as odds ratios with 95 per cent confidence intervals.

Since there is no consensus in literature as to which vari-
13/26 (50.0)
13/26 (50.0)

able is the most representative to define canine position and

6/14 (42.9)
8/14 (57.1)

9.5; 13.9
7.7; 11.9

deciding a range of clinically significant changes in canine

1.1; 3.1

position for any of the included five variables was nearly im-
11.0

2.0
9.0

possible, post hoc power of the sample was performed by a

chi-square test, considering spontaneous canine eruption at
Extraction (2)
Table 1. Sample distribution and pairwise comparisons between groups.

18 months.
15/33 (45.5)
18/33 (54.5)
8/17 (47.1)
9/17 (52.9)

Statistical analysis was performed using SAS software (ver-

8.7; 13.8
7.7; 12.0

1.0; 2.3

sion 9.4 of the SAS System for Windows).

10.8

1.7
9.1

Results
Expansion (1)

11/19 (57.9)
19/35 (57.6)
16/35 (42.4)

Table 1 shows the distribution of the sample. The post hoc

8/19 (42.1)

9.2; 13.6
7.0; 11.2

power of the sample, considering spontaneous canine erup-

1.0; 2.9

tion at 18 months, yielded a power of 0.95 for a total sample

10.7

1.8
8.9

of 68 canines (17 per group).

Figure 2 presents the CONSORT 2010 Patient Flow
Diagram per intervention. Including the control group,
Mean
Mean
Mean

a total of 84 patients met all criteria to be included in this

M

R
R
R
F

RCT, of which 8 dropouts were noted: 6 patients failed to

attend follow up appointments and 2 were not compliant
Follow up period (years)

during treatment. Seventy-six patients with 142 impacted

canines were finally included, with a mean follow up of 1.9
canines n/N (%)
patient n/N (%)

years. Pairwise comparisons between groups for sex, age, and

Age T2 (years)
Age T1 (years)

duration of the follow up period showed no baseline demo-

graphic differences between groups, except for the control
group, which included significantly more boys than the ex-
Sex

pansion group (P = 0.07). No changes in trial outcomes were

G. Willems et al.
Figure 2 CONSORT 2010 flow diagram
made after the start of the trial. No side effects or harms were
observed in any of the included subjects, neither clinically, nor
reported by patients or parents/guardians.
The canine position per group at T1 and T2, as well as the
mean change T2–T1 are summarized in Table 2. It should be
noted that a decrease in values corresponds to clinical im-
provement for all parameters except for 3c-ML, which should
increase for clinical improvement. During the 18-month
study period, the sector only improved significantly in the
expansion group (P = 0.040), while the angle towards the
midline and the distance to the occlusal plane improved sig-
nificantly in all groups. The highest improvement in 3^ML
was registered in the expansion group followed by controls.
The distance between the canine cusp and the midline only
improved significantly in the control group, while no differ-
ences were observed in other groups regarding 3^4. A slight
worsening was seen in both these last parameters in the no
intervention group.
The Pairwise differences in canine position between
groups at T1, at T2, and with respect to the change T2–T1
are reported in Table 3. No significant differences in canine
position were detected between groups at T1, with the ex-
ception of the canines in the expansion group being located
in significantly worse sectors than those in the no interven-
tion group (P = 0.013). Regarding the change between T2
and T1, it can be observed that the sector improved signifi-
cantly more in the expansion group than in the no interven-
tion group (P = 0.028), where a (non-significant) worsening
in sector is also observed at T2. Also at T2, 3^4 improves
significantly more in the extraction group compared to the
expansion (P = 0.015), no intervention (P = 0.000), and
control groups (P = 0.032). This angle also improves more
in controls compared to no intervention (P = 0.037). The
distance between the canine cusp and the midline (non-
significantly) increases in all groups, as the canine moves
5
from above the lateral incisor, except in the no intervention
group. This distance improves significantly more in the ex-
pansion group compared to no intervention (P = 0.038) and
in controls compared to extraction (P = 0.011) and no inter-
vention (P = 0.000) at T2. Also, more displacement of the
canine towards the occlusal plane is observed in controls
compared with the extraction (P = 0.039) and expansion
groups (P = .032) at T2. Here, the change towards T1 is also
significantly larger in controls than in the extraction group
(P = 0.027). Finally, no differences were detected between
groups regarding 3^ML.
Table 4 shows the outcomes of the long-term follow up.
First, the table details whether the canines erupted spontan-
eously during the study period (<18 months of follow up) or
after (18–60 months). At patient level, no significant differ-
ences were detected between groups regarding spontaneous
eruption of the canines <18 months, but spontaneous erup-
tion happened significantly more often after 18 months in the
control group compared to the others (62.5% of the canines
in the control group erupted spontaneously between 18 and
60 months of follow up, compared to 46.15 per cent, 20.00
per cent, and 18.2 per cent in the no intervention, expansion,
and extraction groups respectively; P = 0.043).
Secondly, Table 4 also reports the cases where further
minor or major orthodontic intervention was necessary
during follow up (18–60 months), as well as the probabil-
ities of each group of needing major orthodontic interven-
tion. These probabilities were calculated both at patient and
tooth level and compared between groups. Significantly more
surgical exposure of the canines was necessary in the no
intervention group after the study period. The probabilities
of major intervention were significantly higher in the extrac-
tion and no intervention groups compared to expansion (P =
0.014, P = 0.001, respectively) and controls (P = 0.026, P =
0.001, respectively).
The null hypothesis (none of the studied strategies outper-
forms the others regarding improvement of MC position) is
therefore rejected.
Discussion
Early orthodontic treatment aims to avoid the onset of mal-
occlusion, facilitate dental eruption, and guide growth. It
often involves relatively inexpensive interventions and could
be considered as preventive dentistry. The present study inves-
tigates the effect of SME with removable plates, extraction of
upper DC, or no intervention on MC position during EMD
in a sample of patients with at least one impacted MC, no
crossbite, and lack of space in the upper arch.
The measurements used to determine canine position play
a crucial role in the evaluation of impaction, which in turn in-
fluences treatment outcome (16). Because of this, the present
study takes into consideration five significant predictors of
canine impaction on panoramic radiographs (20,22).
The first parameter taken into consideration is the sector
where the canine is positioned, which has been suggested
by different authors as the most important predictor of ca-
nine impaction (13,18,23). The present study only includes
patients with canines in sectors ≤ 1, as defined by Raes et
al. (20). This corresponds with sectors 1 and 2 as defined by
Ericson and Kurol, where the canine does not cross the axis
of the lateral incisor (19). Our results suggest that SME is the
only intervention that significantly improves the sector at 18
 6

Table 2. Canine position per group at T1 (start), at T2 (18 months follow up), change T2–T1 and its significance.

Group Time point Sector 3^ML (°) 3^4 (°) 3c-ML (proportion) 3c-OP (proportion)

% of canines in sector 0 Mean Range Mean Range Mean Range Mean Range

Expansion T1 65.71 28.97 15.00; 57.10 8.73 −4.90; 38.20 18.05 13.70; 23.47 19.39 7.14; 30.00
T2 85.71 17.15 0.30; 45.20 6.60 -7.30; 21.40 18.81 14.39; 23.38 13.42 0.00; 28.33
Change T2–T1 Mean (95% CI) −0.22 −11.85 (−15.99; −7.71) −2.27 (−5.92;1.38) 0.83 (−0.58;2.24) −6.31 (−9.82; −2.80)
(−0.43; −0.01)
P value 0.040* <.0.000* 0.208 0.234 0.001*
Extraction T1 78.79 25.05 15.30; 43.40 4.20 −16.30; 26.40 17.62 11.70; 21.69 17.84 8.14; 28.17
T2 93.94 16.85 0.20; 34.40 −0.25 −12.30; 20.20 18.24 14.44; 24.22 12.99 0.00; 25.26
Change T2–T1 Mean (95% CI) −0.15 −8.16 (−13.19; −3.13) −3.13 (−6.78;0.53) 0.57 (−0.65;1.80) −4.79 (−6.87; −2.71)
(−0.33;0.03)
P value 0.096 0.003* 0.089 0.336 0.000*
 No intervention T1 96.15 23.85 15.00; 51.00 10.62 −7.90; 80.60 17.37 12.00; 21.43 19.54 11.72; 31.71
T2 92.31 16.13 2.70; 39.90 10.49 −2.50; 51.80 16.94 9.55; 22.25 12.23 0.00; 26.29
Change T2–T1 Mean (95% CI) 0.11 −7.68 (−13.76;-1.60) 0.08 (−4.70;4.86) −0.51 (−2.21;1.19) −7.10 (−10.78; −3.43)
(−0.22;0.43)
P value 0.487 0.017* 0.971 0.529 0.001*
Control T1 85.42 24.98 7.50; 44.20 7.58 −19.80; 63.00 18.41 10.60; 24.36 17.38 9.89; 28.25
T2 95.83 13.76 1.00; 39.50 5.00 −5.80; 18.90 20.18 12.13; 26.10 8.34 −2.88; 27.82
Change T2–T1 Mean (95% CI) −0.10 −11.29 (−15.06; −7.52) −2.57 (−6.88;1.73) 1.77 (0.14;3.41) −9.14 (−11.78;-6.51)
(−0.23;0.02)
P value 0.102 <.0.000* 0.229 0.035* <.0.000*

CI: Confidence Interval; ML: Upper dental midline; NA: Not applicable; OP: Occlusal plane; ^: Angle. *P-values <0.05 are considered significant. Note that the mean values at T1 and T2 do not take into
consideration clustering of teeth in the same patient, while the Change T2–T1 is calculated with the mean estimations given by the statistic model, therefore considering teeth clustering. Negative mean change
values mean decrease from T1 to T2. For sector, negative values correspond to changes from sector 1 to sector 0 (e.g. T2 – T1 = 0 – 1 = −1), which is an improvement of the clinical situation.
European Journal of Orthodontics, 2023
Table 3. Pairwise differences in canine position between groups at T1, T2, and with respect to the change between T1 and T2.

Group Sector (%) 3^ML (°) 3^4 (°) 3c-ML (proportion) 3c-OP1 (proportion)

Mean difference (95% P-value Mean difference P-value Mean difference P-value Mean difference (95% P-value Mean difference P-value
G. Willems et al.

CI) (95% CI) (95% CI) CI) (95% CI)

Expansion vs. At 0.15 0.212 3.49 0.232 4.58 0.211 0.34 0.670 1.62 0.253
Extraction T1+ (−0.09;0.38) (−2.28;9.26) (−2.66;11.83) (−1.23;1.90) (−1.18;4.41)
At 0.08 0.462 −0.17 0.955 6.34 (1.27;11.42) 0.015* 0.60 0.473 0.06 0.981
T2+ (−0.13;0.28) (−6.35;6.01) (−1.05;2.24) (−4.65;4.76)
T2– −0.07 0.618 −3.69 0.247 0.79 0.791 0.25 0.820 −1.57 0.452
T1° (−0.35;0.21) (−10.01;2.63) (−5.15;6.74) (−1.93;2.43) (−5.70;2.57)
Expansion vs. At 0.32 (0.07;0.57) 0.013* 4.86 0.117 −1.68 0.664 0.50 0.553 −0.24 0.874
No intervention T1+ (−1.25;10.97) (−9.36;6.01) (−1.16;2.16) (−3.20;2.72)
At −0.01 0.918 0.71 0.829 −4.16 0.121 1.85 (0.10;3.60) 0.038* 0.55 0.825
T2+ (−0.23;0.21) (−5.83;7.25) (−9.45;1.12) (−4.42;5.53)
T2– −0.33 0.028* −4.17 0.217 −2.41 0.441 1.33 0.256 0.80 0.716
T1° (−0.62; −0.04) (−10.86;2.52) (−8.62;3.80) (−0.98;3.64) (−3.57;5.17)
Expansion vs. At 0.20 0.068 3.37 0.203 0.94 0.777 −0.46 0.523 1.88 0.143
Control T1+ (−0.01;0.41) (−1.86;8.60) (−5.64;7.52) (−1.88;0.96) (−0.65;4.42)
At 0.10 0.307 2.84 0.315 1.14 0.617 −1.41 0.065 4.68 (0.42;8.94) 0.032*
T2+ (−0.09;0.28) (−2.76;8.44) (−3.39;5.67) (−2.90;0.09)
T2– −0.10 0.444 −0.56 0.845 0.31 0.907 −0.97 0.332 2.81 0.139
T1° (−0.35;0.15) (−6.29;5.16) (−5.00;5.62) (−2.95;1.01) (−0.93;6.56)
Extraction vs. At 0.17 0.181 1.37 0.662 −6.26 0.115 0.16 0.851 −1.85 0.226
No intervention T1+ (−0.08;0.43) (−4.87;7.61) (−14.09;1.57) (−1.53;1.85) (−4.88;1.17)
At −0.09 0.435 0.89 0.792 −10.50 0.000* 1.26 0.163 0.50 0.846
T2+ (−0.31;0.13) (−5.79;7.56) (−15.98; −5.03) (−0.52;3.04) (−4.59;5.59)
T2– −0.26 0.087 −0.48 0.890 −3.20 0.322 1.08 0.364 2.37 0.295
T1° (−0.56;0.04) (−7.31;6.36) (−9.61;3.21) (−1.28;3.43) (−2.11;6.84)
Extraction vs. At 0.05 0.646 −0.12 0.965 −3.64 0.285 −0.79 0.282 0.27 0.838
Control T1+ (−0.17;0.27) (−5.50;5.26) (−10.39;3.10) (−2.25;0.67) (−2.34;2.88)
At 0.02 0.835 3.02 0.300 −5.20 0.032* −2.00 0.011* 4.63 (0.23;9.02) 0.039*
T2+ (−0.17;0.21) (−2.74;8.78) (−9.94; −0.46) (−3.53; −0.47)
T2– −0.03 0.831 3.13 0.293 −0.48 0.863 −1.22 0.234 4.38 (0.52;8.24) 0.027*
T1° (−0.29;0.23) (−2.76;9.03) (−6.03;5.07) (−3.25;0.81)
 No inter- At −0.12 0.305 −1.49 0.606 2.62 0.472 −0.95 0.227 2.12 0.133
vention vs. T1+ (−0.36;0.11) (−7.23;4.25) (−4.60;9.84) (−2.51;0.61) (−0.66;4.90)
Control At 0.11 0.299 2.13 0.491 5.30 (0.33;10.27) 0.037* −3.26 0.000* 4.13 0.083
T2+ (−0.10;0.31) (−4.02;8.28) (−4.90; −1.62) (−0.55;8.81)
T2– 0.23 0.097 3.61 0.256 2.72 0.355 −2.30 0.038* 2.01 0.332
T1° (−0.04;0.51) (−2.68;9.89) (−3.11;8.55) (−4.47; −0.13) (−2.10;6.13)

CI: Confidence interval; NA: Not applicable. *P-values <0.05 are considered significant. +Negative mean differences mean lower values in the first group than in the second. The lower the values, (the closer to 0),
the more improvement, except for 3c-ML. °Negative values mean lower change score (and therefore more change) in the first group than in the second.
7
 8

Table 4. Long term follow up (> 18 months): Spontaneous canine eruption during (<18 m) and after the study period (18–60 m) and comparisons between groups at tooth and patient level based on the type of
orthodontic intervention performed after the study period.

Total per group Spontaneous eruption Minor orthodontic intervention after Major orthodontic intervention after study period Probabilities of needing major orthodontic
study period (18–60 m) (18–60 m) intervention

<18 m 18–60 m a b Total c d e f Total At patient level At tooth level

P OR (95% CI) P

Expansion (1) canines (%) 35 (100) 5 (14.3) 7 (20.0) 8 (22.9) 8 (22.9) 16 (45.7) 2 (5.7) 4 (11.4) 1 (2.9) 0 (0.0) 7 (20.0) 1 vs 2 0.036* −11.43 (−1.63; −79.97) 0.014*
patients (%) 19 (100) 3 (15.8) 4 (21.05) 4 (21.0) 4 (21.05) 8 (42.1) 1 (5.3) 2 (10.5) 1 (5.3) 0 (0.0) 4 (21.05)
Extraction (2) canines (%) 33 (100) 3 (9.1) 6 (18.2) 2 (6.1) 2 (6.1) 4 (12.1) 9 (27.3) 5 (15.1) 6 (18.2) 0 (0.0) 20 (60.6) 1 vs 3 0.013* – 0.001*
patients (%) 17 (100) 2 (11.8) 4 (23.5) 1 (5.9) 1 (5.9) 2 (11.8) 3 (17.6) 3 (17.6) 3 (17.6) 0 (0.0) 9 (52.9)
  
No Inter- canines (%) 26 (100) 2 (7.7) 12 (46.15) 0 (0.0) 0 (0.0) 0 (0.0) 2 (7.7) 5 (19.2) 3 (11.5) 2 (7.7) 12 (46.15) 1 vs 4 1.000 −0.91 (0.12; 7.08) 0.932
vention patients (%) 14 (100) 1 (7.1) 6 (42.9) 0 (0.0) 0 (0.0) 0 (0.0) 1 (7.1) 2 (14.3) 2 (14.3) 2 (14.3) 7 (50.0)
(3)
 Control (4) canines (%) 48 (100) 6 (12.5) 30 (62.5) 8 (15.4) 0 (0.0) 8 (16.7) 0 (0.0) 0 (0.0) 4 (7.7) 0 (0.0) 4 (8.3) 2 vs 3 0.497 – 0.276
patients (%) 26 (100) 4 (15.4) 15 (57.7) 5 (19.2) 0 (0.0) 5 (19.2) 0 (0.0) 0 (0.0) 2 (7.7) 0 (0.0) 2 (7.7)
 Pairwise comparisons at patient level 0.934 0.043* 0.214 0.031* 0.004* 0.096 0.111 0.623 0.032* 0.002* 2 vs 4 0.049* 12.50 (1.75; 60.36) 0.026*
(P value)
3 vs 4 0.021* – 0.001*

a: Extraction of deciduous canines or first molars; b: Spring or coil; c: Extraction of 14 and 24; CI: Confidence interval; d: Transversal expansion; e: Sagittal expansion; f: Surgical exposure of the canine; m:
months; OR: Odds ratio. *P-values smaller than 0.05 are considered significant. Pairwise comparisons were used at patient level. Logistic regression with estimation based on generalized estimation equations was
used for comparisons at tooth level, in order to take into account the clustering of teeth within patients. Positive odd ratios show higher probability for major orthodontic intervention in the first group. Due to zero
cases with minor orthodontic intervention in the no intervention group, no odd ratios could be estimated and comparisons were performed by a Fisher exact test.
European Journal of Orthodontics, 2023
G. Willems et al.
months of follow up. It is relevant to note that the canines
in the expansion group were located in worse sectors at T1
compared to those of other groups (Table 1) and that not
intervening worsened the sector: in the no intervention group,
3.84 per cent of the canines with sector 0 at T1 displaced to
a worse sector.
The canine-to-midline angle (3^ML) has also been indi-
cated as an important predictor of canine impaction (19,24–
26), although Warford et al. found the sector to be a better
predictor of impaction and 3^ML to add little supplemen-
tary predictive value (18). A canine-to-midline angle of ≥15°
has been indicated in literature as a predictor of high risk for
canine impaction in 8–9 year olds (23), reason why it was
used in this study as an inclusion criterion to define impac-
tion. In our sample, this angle decreased significantly in all
groups, indicating further canine uprighting. The largest im-
provement was found in the expansion and control groups.
Literature suggests that extraction of DC does not alter the
relationship between the lateral incisor and the permanent ca-
nine, while maxillary expansion would lead to a change in the
intra-osseous anatomical position of the canine, which could
explain these results (12). Caprioglio et al. (15) found RME
to improve 3^ML significantly more than SME with quad-
helix appliance in a retrospective sample with a mean age of
±8.5 years over a 12 month follow up period. However, these
patients presented 3^ML<15° at baseline and no other canine
position measurements were reported.
The position of the canine towards the premolar (3^4)
was also analysed in the present study. Although 3^4 ≥48.2°
has been suggested as a cut-off value for impaction (22), the
mean values of our sample were much lower, probably be-
cause measurements were performed at an earlier stage of
tooth development. In addition, unlike the dental midline,
the premolar displaces as well, which means the reference
point changes. This could also explain why no differences in
3^4 were detected between T1 and T2 in any of the groups.
Extraction of DC was the interceptive measure improving this
angle the most, while no intervention led to the worst 3^4,
significantly larger than those of the control group.
The distance between the canine cusp and the midline has
been considered to have the best discriminatory power to pre-
dict spontaneous eruption of palatally impacted canines, with
a cut-off value of 11 mm (4). However, no absolute compari-
sons can be made with our dataset regarding this parameter,
since we determined it as a ratio to the crown width of the
contralateral central incisor, in order to avoid performing
linear measurements in panoramic radiographs, which can
lead to bias. In our study, 3-ML decreased in the no interven-
tion group at T2, instead of increasing like in other groups.
Again, this parameter improved the most in controls without
a lack of space.
Sajnani and King found a significant difference in 5-year-
old children regarding 3c-OP between impacted and non-
impacted canines (24), which is in line with the findings of
other authors (25–28). During our 18-month follow up, sig-
nificantly larger intra-osseous vertical eruption was observed
in the control group compared to the expansion and extrac-
tion groups.
In summary, within the 18-month study period, SME with
removable plates and extraction of the DC both seemed ac-
ceptable treatments in patients with impacted canines, no
crossbite, and lack of space in the upper arch, with expan-
sion performing better regarding sector improvement. On
9
a longer term however (18–60 months), SME reduced the
need and complexity of subsequent orthodontic treatment.
In our sample, significantly less major orthodontic interven-
tions were needed in patients who received expansion. The
chances of these patients to receive orthodontic treatment
equalled those of controls with sufficient space in the dental
arch. Surgical exposure of the canine was significantly more
likely in the no intervention group. Also, extraction of defini-
tive premolars happened more often in patients where DC
were previously extracted. One third of the control patients
(37.5%) still needed intervention after the study period and
maxillary expansion was still required in 15 per cent of the
patients of the extraction and no intervention groups, which
could have been prevented. In patients where expansion was
performed, our protocol included evaluation of canine pos-
ition on panoramic radiographs. Extraction of the DC was
then performed in case their roots were not visibly resorbed
or in case of eruption cysts, together with the first primary
molars in case of 1. persistent lack of space, 2. first premolar
positioned to erupt before the definitive canine, or 3. 3^ML
≥ 45°.
Despite the randomization of the interceptive approaches
and the prospective study design being important assets of
the present study, some limitations are worth mentioning.
Firstly, while other authors excluded patients with maxillary
crowding >2 mm (4), we did not. Secondly, no distinction was
made between labial and palatal impaction, which are con-
sidered aetiologically different (29). This is due to the young
age of the included patients at the start of the trial (mean age
9 years old). At this age, canines are still high in the maxil-
lary process (30) and cannot be diagnosed yet as palatally or
buccally impacted. At this moment, impactions are not yet
severe and early intervention is able to correct the eruption
pathway of the MC. Lastly, although panoramic radiographs
are routinely taken for diagnostic purposes in orthodontics,
they are prone to magnification, overlap, distortion, and
errors during imaging taking (31). However, correct posi-
tioning of the patient’s head provides sufficient accuracy for
relative linear and angular measurements (32,33).
Our study suggests that taking a first panoramic radio-
graph around 8 years of age is effective in diagnosing MC
impaction based on sector and canine-to-midline angle, which
is in line with the guidelines of the American Academy of
Pediatric Dentistry (34). With this first diagnostic image, early
screening of canine impaction and interceptive orthodontic
interventions can be performed by the general practitioner,
which could reduce the burden on specialists, since expansion
plates are simple, cost-effective appliances. In future research,
patient satisfaction, pain perception, and cost-efficiency
should be taken into consideration, in order to strengthen the
arguments regarding the best approach for early intervention
of MC impaction.
Conclusion
In patients with impacted MCs, no dental crossbite, and
lack of space in the upper arch, SME results in significant
improvement of the sector where the canine is positioned
and decreases the need for major orthodontic intervention
in the long term, compared to extraction of DC or a wait-
and-see attitude. Panoramic radiographs in EMD can help
identify potential permanent canine impaction and future
follow up.
10
Acknowledgements
We would like to thank Mrs. Annouschka Laenen for per-
forming formal statistical analysis.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The authors have no conflict of interest.
Data availability
All data are incorporated into the article.
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