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European Journal of Orthodontics 10 (1988) 283-29 5

1988 European Orthodontic Society

Early treatment of palatally eruptin g maxillary canines by extractio n of th e primary canines

Sune Ericson an d Jur i Kurol

Jonkoping, Sweden

SUMMAR Y The effect of extraction of th e primary

canine on palatally erupting ectopi c maxillary

canines was analysed. There were 46 consecutive ectopic canines, in 35 individuals , aged 10.0 -

  • 13.0 years (mean age 11. 4 years) at th e tim e of discovery of the ectopic eruption . Al l cases

showe d no or mino r space loss. After extraction of the primary canine, the childre n wer e

investigated clinicall y and radiographed at 6-mont h intervals fo r up t o 18 months.

In 3 6 of th e 4 6 canines

(78% ) the palatal eruptio n changed t o normal;

23

already showe d

improved position s after 6 months and 1 3 after 12 months . No new cases normalized after 1 2 months.

We suggest tha t extraction of the primary canine is the treatment of choice in youn g individual s t o correct palatally ectopicall y eruptin g maxillary canines provided that normal space condition s

are present and no incisor root

resorptions are found .

Introduction

The maxillary permanent canine is second only to the third molar in frequency of impaction, with a prevalence of approximately 2 per cent of the population (Thilander and Jakobsson, 1968; Ericson and Kurol, 1986a). The canine is found palatal to the dental arch in about 85 percent of the cases and buccal only in about 15 percent (Hitchin, 1956; Rayne, 1969; Ericson and Kurol, 1987a).

If orthodontic treatment is not started, there is always a risk of retention and also of resorp- tion of the roots of the permanent incisors. Such resorptions have recently been reported to occur in 12 percent of cases of ectopic eruption of the maxillary canines in the age range 10-13 years (Ericson and Kurol, 1987a). Resorptions may be found as early as 10 years of age but occur most often in the age groups 11 to 12 years (Ericson and Kurol, 1987b).

The most common treatment procedure in children and adolescents is surgical exposure followed by orthodontic appliance treatment, where, as a rule, the primary canines are left in place until the orthodontist has moved the impacted tooth to this region (Moyers, 1973; Clark, 1971; Bishara et al., 1976; Hunter, 1983a, b; Fleury et al., 1985). Other proposed

strategies

are

1.

acceptance,

i.e.

no

treat-

ment, 2. extraction of the malerupting canine, and 3. surgical repositioning (Richardson and McKay, 1983).

Several aetiological factors for ectopic canine eruption have been proposed, and include her- editary factors, lack of space, persistence of

primary canines, a true ectopic path of eruption, reduced root length or aplasia of lateral incisors

(Richardson and

McKay,.

Becker et al., 1984).

.1982; Jacoby, 1983;

Delayed exfoliation of the primary canine was believed by Lappin (1951) to be the principal aetiological factor and he presumed that it would be possible to prevent the condition from occurring in a great many cases, by extracting the primary canine. This was also suggested by Miller (1963) and Williams (1981). Berger, in 1943, stated tha t widening of the arch in the premolar region and early extraction of the primary canines were advisable as precautionary measures to prevent incisor root resorptions.

A thorough search of the literature has shown that sporadic case reports where extraction of the primary canine has favourably influenced the future pat h of eruption have been pre- sented over the last 50 years (Buchner, 1936; Kettle, 1957; Lind, 1977; Williams, 1981; Leives- ley, 1984). In some of the presented case reports,

ECTOPIC MAXILLARY CANINES

28 7

Table 3 Distribution o f the medial position of the maxillary permanet canine in sectors 1-4 in the vertical plane as shown in the orthopantomogram. N o teeth were in sector 5. A t the start o f treatment, after 12 and after 18 months. Number and percent.

Medial maxillary canine crown position in sector

Registration

1

2

3. 4

Total number

n(%)

n(%)

n(%)

At start

13(28)

11(24)

22(46)

46

(n =

46 )

12

month s

28*(61)

9(20)

9(20)

46*

after

extraction

 

(n =

37)

18

months

36*(78)

2(4)

8(17)

46*

after

extraction

 

(n =

24 )

* 9 canines had normal positions at the 6-month radiographic control and another 13 at the 12-month control.

Table 4

The distribution o f the canine crown position relative to the

midline o f the dental arch in the horizontal plane as shown in the axial- vertex radiogram. A t the start o f treatment, 12 months and 18 months after extraction o f the primary canine. Number and percent.

 

Position

relative t o the dental arch

 
 

Central

 

Palatal

or buccal

Registration

Palatal

tendency

tendency

Total number

n(%)

n(%)

n(%)

At start

 

27(59)

19(41)

46

(n

=

46 )

12

months

9(20)

15(33)

22(48)*

46*

after extraction

 

(n

=

37)

18

months

8(17)

2(4)

36(78)*

46*

after extraction

 

(n

=

24 )

* 9 canines had normal positions at the 6-month radiographic control and another 13 at the 12-month control.

than half of the roo t at the start of treatment, 22 (91%) normalized (Table 2, Fig. 4). The

3) showed concordant results and will not be reported in detail,

change in medial canine crown position in re- lation to time after extraction can be seen from Position relative to the dental arch

Table 3, where eight of the ten teeth with no The distribution of the canine crown position

final normalization belonged to sectors 3 and 4

and one to sector 2 a t the start. The positions

of

the canines in

the vertex projection

(Fig.

relative to the midline of the dental

arch

is

shown in Table 4. Of the 27 canines (59%) in a

lingual position at the start of treatment (22 in

ECTOPI C MAXILLARY CANINE S

Tabl e 5

Mesia l inclinatio n (degrees) o f th e canin e t o th e midlin e in th e

orthopantomogram . Mea n valu e an d

standar d deviatio n a t th e different

registration s an d mea n difference an d level of significance.

289

 

Level of

 

Registration

 

s.d.

d±s.d .

 

significance

At start

 

22.0

11.1

(n =

46)

6-month

 

17.9

12.5

4.1+8. 3

 

p <

0.01

control

 

(n =

46)

12-month

 

14.0

13.3

13.3

9.8

+ 9.1

p <

0.001

control

 

(n =

37)

Tabl e 6

Th e distanc e (mm ) from

th e canin e cus p

t o

th e occlusa l

plan e

 

i n th e orthopantomogram . Mea n

valu e an d standar

d deviatio n

a t

th e

differen t registration s an d mea n difference an d level o f significance .

 

Level of

Registration

mean

s.d.

d±s.d .

 

significance

At start

 

14.7

3.2

(n =

46)

6-month

 

11.7

4.3

3.0

±1. 8

p <

0.01

control

 

(n =

46)

12-month

 

9.2

5.0

5.5

±2.

7

p <

0.001

control

 

(n =

37)

Table 7

Treatmen t

procedure s

for

10

ou t

of

th e

46 ectopi c

maxillary

canines

wher e

n o

improvemen t

of positio n was registered

12 month s after extractio n of th e primar y

canine .

 

Change of eruption path

Treatment

 
 

Orthodontic

 

Position in the

impaired

surgical

 

fixed appliance

' Extraction

orthopantomogram

No change

position

exposure

treatment

 

of lateral

 

Overlapping

less than half

of the

lateral (sectors 1, 2)

 

Overlapping

more than

half of the

lateral (sectors 3, 4)

6

2

  • 8 2

8

 

Total

8

2

  • 9 2

8

ECTOPIC MAXILLARY CANINES

291

clinical experience, it is not likely that ectopically erupting canines will be spontaneously corrected to such an extent, especially not those with the crown in advanced medial positions, as shown in Figures 2 and 4, Table 2. However, a few of the canines in the youngest age groups with a moderate dislocation of the canine might have corrected spontaneously, as shown by us earlier (Ericson and Kurol , 1986a). Fo r ethical reasons, we have not been able to design a study with a traditional, untreated control group but it is hardly likely that 22 of 24 canines (92%) in sectors 1 and 2 and 14 of 22 (64%) in sectors 3 and 4 (in the orthopantomogram) would do so. The results will be discussed with this assumption and reservation. A positive change in the path of eruption could be observed radiographically in 50 per

or improved positions. If such a change in eruption is not detectable at tha t time, a new decision must be made and some canines posing a risk of further root resorption of the incisors, may have to be surgically exposed and treated with orthodontic appliances, while in most other cases a further 6 months of observation may be allowed. If no improvement is detectable at the 12-month control, we suggest alternative treatment. If the diagnosis is made early accord- ing to denned criteria i.e. clinical palpation and if necessary radiographic examination (Ericson and Kurol, 1986a), there should be enough time to carry out alternative surgical and/or orthodontic treatment. This study has clearly demonstrated the favourable effect on the maxillary canine even in very medial positions of the canine crown

cent of the cases, and in some cases (20%)

(Table 3, Figs. 1 and 6) and up to a

mesial

also clinically, at the 6-month registration after

inclination of the canine of 55 degrees

to the

extraction of the primary canine (Figs. 1 and 6). At the 12-month control, all but nine had normal

midline in the orthopantomogram (Table 6). Note that canine teeth with similar positions

Figure 7 Palatal ectopi c eruption o f both maxillary canines in a boy aged 12 years 11 months at the start o f treatmen t Mixed dentition period. The width o f the dental follicle exceeded 3 mm fpr both canines. ID the orthopantomogram (A ) the mesial inclination t o the midline is 31 degrees for the left canine and 27 degrees for the right canine. In the axial-vertex projection (B) the cus p tips are positioned approximately in the same position lingually t o the lateral incisor roo t Twelve months after extraction o f the maxillary primary canines the orthopantomogram ( Q and axial-vertex projection (D ) sho w an improved position o f the left canine and a slightly impaired position o f the right maxillary canine.

292

SUN E ER1CS0 N AN D JUR I

KURO L

Figure 8

Girl aged 12 years 8 month s at the start o f treatment. Th e right maxillary canine is erupting palatally an d the

orthopantomograms, axial-vertex radiographs and intra-oral radiographs show the development from the start (A , C, E) to

  • 12 months after extraction o f the

primary canine (B , D , F) .

and angulations may react differently even in the same individual, as shown in Figure 7. In spite of a difference of only four degrees in mesial angulation and concordan t medial and lingual positions, the left maxillary canine nor- malized but not the right. Due to the difficulty in predicting a favourable change of the path of eruption in the individual case, we recommend radiological and/o r clinical supervision at six- month intervals after extraction of the primary canine until the permanen t canine erupts.

The degree of palata l position a t the start of treatment relative t o th e dental arch has been shown to influence th e result (Table 4). Maxillary canines with a moderate lingual pat h of eruption normalized more often (90%) than canines in true lingual positions (65%). Again, no reliable forecast of success o r failure can be made in the individual case, althoug h the prognosis for the treatment o n the whole is very good. With earlier diagnosis according t o ou r earlier recommen- dations (Ericson and Kurol , 1986b), it may be possible t o achieve even better results as the

canine is then higher up and probably ha s a less deflected path of eruption. Not e that one-third of the patients in this study were between 12 and 13-years-old at the time of referral. It has often been mentioned that a palatal path of eruption may be seen in cases where the primary canine is unresorbed (Dewel, 1949; Hotz, 1974; Salzmann, 1974). However, it is not established whether this is a consequence or the primary cause of the ectopic palatal eruption. In this study, in individuals aged 10-13 years, i.e. during a normal eruption period, 21 (46%) of the 46 primary canines were unresorbed and 25 (54%) showed various degrees of resorption. In order to be successful with this procedure of extracting the primary canine, we must follow the eruption process radiologically by means of correct and standardized radiographs. If this is done, it will be possible to record even slight or moderate ehanges, as studies of distortion in rotational panoramic radiography and cephalo- graphy have demonstrated great tolerance with respect to angular and vertical distortions

ECTOPt C MAXILLAR Y

CANINE S

293

Figure 9 Girl aged 11

years at the start or treatment (A , C, E) and 12 months later (B , D , F); an impaired positio n o f the

left maxillary canine is evident in the orthopantomogram, axial-vertex projection and intra-oral radiograph.

(Tronje, 1982; McDavid et al., 1985; Ahlqvist et al., 1986). Based on these reports, and applying a relative scale for the mesio-distal and bucco- lingual determinations, it can be claimed that the registrations in this study have been per- formed with moderate errors, acceptable for practical clinical purposes in the everyday clini- cal situation. Used together, we consider the methods describe the displaced canine and the changes in position with sufficient accuracy in three dimensions and are suitable for this clinical purpose. Guilford's coefficient of reliability (Guilford, 1965) was high for all our measure- ments (Ericson and Kurol, 1988).

In view of the positive results of this study we suggest that primary canine extraction is the treatment of choice in the age-group 10-13 years when the permanent maxillary canine has a palatal ectopic pat h of eruption. Before the age of 10, spontaneous correction of potentially malplaced canines may occur (Ericson and Kurol, 1986b) and extraction is normally not indicated unless a very early somatic and dental development is found. With late diagnosis o r

crowding and in cases of resorption or very horizontal paths of eruption, alternative modes of treatment should be considered, as our experi- ence of the method in such cases is too small. Surgical exposure with subsequent orthodontic appliance treatment will be the main choice in those cases.

Early extraction of the primary canine in order to correct the malerupting maxillary permanent canine has considerable advantages for the child, both economically and in terms of the discomfort that result from more traditional treatment ap- proaches. In fact, periodontal damage to the ectopic canine after surgical exposure and ortho- dontic alignment has been reported compared to control canines (Wisth et al., 1976 a,b; Hans- son and Under-Aronson, 1972; Boyd, 1982; Kohavi et al., 1984; Oliver and Hardy , 1986). Incisor devitalization and some loss of alveolar bone support may also occur (Proffit and Acker- man, 4985).

The characteristics of those cases with no

change or an impaired position further analysed.

have

to

be

294

Conclusions and recommendations

It has been clearly shown tha t extraction of primary canines in the uppe r ja w has a favour- able effect on palataUy erupting maxillary can- ines in most cases, if this extraction treatment is performed in time. Early diagnosis of malerup- tion is important for success. The ectopic pos- ition and the pat h of eruptio n of the maxillary canine should preferably be identified before the age of 11. When a favourable effect of treatment occurs, the change in position and in the pat h of eruption will be observed at the latest 12 months after the extraction of the primary canine. If no improvement can be found at tha t time, normal- ization is no t to be expected and alternative treatment should be considered. Due to the great individual variation in the position of the maxillary canines at the star t of treatment and to some extent also in the response to treatment, it is not possible to predict success or failure in the individual case, although the prognosis for the treatment on the whole is very good. Clinical and/o r radiological controls a t six-month inter- vals are recommended. In view of the positive results, we suggest that primary canine extraction is the treatment of choice in the age-group 10-13 years when the erupting permanent maxillary canine has a pala- tal ectopic path of eruption. With later diagnosis or crowding, and in cases of resorption of the incisor roots or a very horizontal path of eruption, alternative modes of treatment should be considered.

Address for correspondence:

D r Juri Kurol Department of Orthodontics The Institute for Postgraduate Dental Education Jarnvagsgatan 9 S-552 55 Jonkoping Sweden

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