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CASE REPORT

Transposition of a maxillary canine and a lateral incisor and use of cone-beam computed tomography for treatment planning
Jason Pair Valencia, Calif This report describes the orthodontic treatment of a 12-year-old girl with transposition of the maxillary left canine and the lateral incisor. Cone-beam computed tomography was used during treatment planning. The transposed tooth positions were corrected with an unconventional orthodontic approach. Treatment alternatives and their clinical concerns are presented. (Am J Orthod Dentofacial Orthop 2011;139:834-44)

ransposition is dened as an unusual type of ectopic eruption where a permanent tooth develops in the position normally occupied by another permanent tooth.1 It is a rare occurrence that affects less than 1% of the population.2-5 Transposition affects the maxillary dentition (68.5%-76%) more frequently than the mandibular dentition.6-8 The most common type of transposition (55%-70%) is that of the maxillary canine and the rst premolar (Mx.C.P1).4,6,9 Twenty-seven percent of Mx.C.P1 patients demonstrate bilateral occurrence.8 Maxillary canine-lateral incisor transposition (Mx.C.I2) is the second most common type at 20% to 42%, with only 5% having bilateral occurrence.8,9 Peck et al10 described Mx.C.P1 as an anomaly resulting from genetic inuences within a multifactorial inheritance model. This was based on an elevated frequency of associated dental anomalies, elevated bilateral occurrence (27%), familial occurrence (11%), and differences between male and female prevalence (females 1.55:1 males).10,11 Others have demonstrated elevated frequencies of associated dental anomalies with Mx.C.P1 patients.6,9,11-13 These associated dental anomalies included hypodontia, submerged deciduous teeth, retained deciduous teeth, and supernumerary teeth. Unlike Mx.C.P1, it has been hypothesized that the etiology of Mx.C.I2 is more environmental than genetic.
Private practice, Valencia and Northridge, Calif; volunteer faculty, Orthodontic Residency Program, University of California at Los Angeles. The author reports no commercial, proprietary, or nanical interest in the products or companies described in this article. Reprint requests to: Jason Pair, 23838 Valencia Blvd, Suite 42, Valencia, CA 91355; e-mail, jpair@hotmail.com. Submitted, July 2009; revised and accepted, August 2009. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2009.08.035

Dentofacial trauma in the deciduous dentition, with subsequent drifting of the developing permanent teeth is the most common etiologic factor.2,8 There are few reports of familial occurrence or dental anomalies associated with Mx.C.I2 transpositions.14 The only dental anomaly that has an apparent association with Mx.C.I2 is increased third molar agenesis.15 Treatment of Mx.C.I2 depends on many factors. If the central incisor has signicant root resorption (either from past dentofacial trauma or due to the ectopically erupting canine), the central incisor can be extracted and the canine moved into its position, as has been reported.16 Signicant restorative work is necessary for acceptable smile esthetics with this treatment plan. If extractions are indicated because of severe crowding or a desire for a change in the soft-tissue prole, then the following extraction pattern should be considered: the transposed canine and the 3 rst premolars in the remaining quadrants. If this option is chosen, it could be necessary to intrude the rst premolar next to the lateral incisor so that the height of the gingival margin matches that of the contralateral canine. The premolar crown could then be veneered and brought into occlusal function. It also might be necessary to extract the transposed lateral incisor (rather than the canine) if it has already demonstrated root resorption. Extraction of transposed peg-shaped lateral incisors and substitution of canines has also been described.14 Another possibilityleaving the canine and the lateral incisor transposedis rarely a good esthetic or functional option. The difculty of resolving the transposition is the risk of root interference as the canine passes distally around the lateral incisor. This interference could lead to signicant root resorption and subsequent pathologic

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tooth mobility of the affected teeth. However, resolving the transposition is ideal for esthetics and function.
DIAGNOSIS AND ETIOLOGY

A girl, aged 12 years 5 months, came to my practice with the chief complaint of malaligned teeth (Figs 1 and 2). She was physically healthy with no history of dental trauma. She had a slightly convex prole with mild chin asymmetry to the right. She had a pleasing smile and lip competence. The intraoral examination showed half-cusp Class II molar relationships with crowding of 3.5 mm in the mandibular arch and 9 mm in the maxillary arch. The maxillary left canine was blocked out of the arch, and the maxillary left lateral incisor was proclined labially. The maxillary left canine could not be palpated labially or palatally. Her maxillary dental midline was displaced 2 mm to the left of the facial midline and mandibular dental midline. Overbite was 25% with an exaggerated curve of Spee of 3 mm. The panoramic radiograph showed normal root and tooth development, with the exception of transposition of the maxillary left canine and the lateral incisor (Fig 3). Cephalometric assessment showed a Class I, mesofacial skeletal pattern (Wits, 1.5 mm; ANB, 2.5 ; SN-GoGn, 33 ) with normally inclined incisors (Fig 4, Table).
TREATMENT OBJECTIVES

3.

4.

Ideally, the treatment objectives would include full resolution of the transposition. However, achievement of this objective might subject the transposed teeth to mechanics that have signicant root resorption risks. Class I molar and canine relationships, ideal overjet and overbite, and an esthetic smile with minimal change in the prole were desired.
TREATMENT ALTERNATIVES

likelihood of ideal smile esthetics. The advantage is the minimal risk of root interferences during alignment. There is also less chance of bony loss of the buccal cortical plate of the canine, since it does not have to pass labially to the lateral incisor. Extraction of the maxillary left lateral incisor (22), normalization of the canine, and a future implant in the lateral position. This would be considered if, when analyzing the initial records, signicant root resorption was found on the lateral incisor. The advantage is a relatively short treatment time. However, the future cost of an implant-supported crown must be considered. Nonextraction treatment with full resolution of the transposition. This plan has been described previously in the literature.1,2,17 One disadvantage of resolving a transposition is the likelihood of a protracted treatment time, as has been demonstrated previously.1,2,17,18 Another disadvantage is the likelihood of root resorption to the lateral incisor if root interferences are not eliminated during mechanics. Also, there is the potential for loss of the buccal cortical plate on the canine as it passes distally and labially to the lateral incisor. It was explained to the patients family that, if the lateral incisor suffered signicant root resorption, it would be extracted, the canine would be normalized, and a future implant-supported crown would be placed in the lateral incisors position (alternative 3).

All treatment options would achieve an ideal Class I molar relationship and ideal overjet. However, the patient and her parents wished to avoid postorthodontic restorative work if possible and were willing to accept a protracted treatment plan (alternative 4). The risks of root resorption to the lateral incisor and loss of the buccal bony plate on the canine were understood and accepted by the patient.
TREATMENT PROGRESS

The following treatment alternatives were considered and discussed with the patient and her parents. 1. Extraction of 3 rst premolars (14, 34, 44) and the transposed canine (23) with intrusion of the maxillary left rst premolar (24) to match the gingival height of the contralateral canine. After orthodontic treatment, a veneer would be placed on tooth 24 to match the morphology of the contralateral canine and bring it into occlusion for canine disclusion. Extractions without careful anchorage control could negatively affect her prole. Nonextraction treatment without resolution of the transposition followed by postorthodontic veneers in an attempt to normalize crown morphology and create ideal function. The disadvantage is the un-

2.

The exact relative positions of the transposed teeth were impossible to ascertain on the pretreatment panoramic radiograph. We instead planned on initially leveling the maxillary arch (with no bracket on 22, except for a metal pad to satisfy the patient, who was selfconscious about having a front tooth without a bracket attached). After leveling, we planned to open space for the transposed teeth, followed by more radiographs and, possibly, a cone-beam computed tomography (CBCT) scan to better assess the position of the canine relative to the root of the lateral incisor. Fixed appliances (self-ligating Damon2, 0.022-in slot; Ormco Corporation, Orange, Calif) were placed in

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Fig 1. Pretreatment photographs.

the maxillary arch in May 2005. A nickel-titanium (NiTi) open coil was used to gain more space for the transposed teeth. Radiographs taken after the arch was leveled did not clearly show the relative tooth positions (Fig 5); an occlusal image suggested that the canine crown was palatal to the root of the lateral incisor, but the periapical images suggested that the crown of the canine was buccal to the lateral incisor root.19 A CBCT scan was obtained in December 2005 (Fig 6). The scan and the composite video showed a complete transposition, with the crown of the canine buccal to the root of the lateral incisor, yet palatal to the crown of the lateral incisor (still images, Fig 6). Bracket placement and archwire engagement at this time on the lateral incisor would bring the root labially and into the crown of the canine, most likely leading to root resorption. Surgically exposing the canine and pulling it distally would drag the crown of the canine across the cervical junction of the lateral incisor, also a risky proposition. It appeared instead that, if the lateral incisor could be simply tipped palatally, it would create enough space to bring the canine into the arch without engaging the lateral incisor

on its way down. A palatal bar was fabricated with soldered hooks; the bar and buttons were placed on the crown of the lateral incisor. The lateral incisor was activated with a power chain (Fig 7). After 6 weeks, a second CBCT scan was taken. It showed complete separation of the lateral incisor root and the canine crown (still images, Fig 8). A path had been cleared for surgical exposure and traction of the canine. No root resorption was noted on the lateral incisor. The canine was brought into the arch with a light 0.014-in NiTi wire (in the bracket slots), while the arch form was stabilized with a stainless steel overlay arch (0.016 3 0.025 in) (Fig 9). The overlay arch was ligated over the closed doors of the self-ligating brackets. This mechanical setup allows for minimal friction acting on the leveling arch as it pulls the canine down, while the integrity of the arch is maintained with the stainless steel archwire. The manner in which the overlay wire is ligated to the brackets (over the wings) does not allow the ligation wires to interfere with the slots of the bracket, so the 0.014-in NiTi wire can slide through with minimal friction. After the canine was brought into the arch, the

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Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs showed normal root and tooth development with the exception of the transposition of the maxillary left canine and the lateral incisor.

Fig 4. Pretreatment cephalometric tracing showed a Class I mesofacial skeletal pattern (Wits, 1.5 ; ANB, 2.5 ; SN-GoGn, 33 ) with normally inclined incisors.

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Table. Cephalometric analysis


SNA SNB ANB Wits SN Go-Gn FMA Max 1-NA Max 1-SN Mand 1-NB Mand 1-Go-Gn E-line Pretreatment 75 72.5 2.5 1.5 mm 31.5 29.5 4 mm 93.5 5 mm 91 0 mm Posttreatment 76 75 1 3 mm 37 28 8 mm 105 7 mm 96 1 mm

lateral incisor was released from traction, and the canine was distalized into its normal position. The lateral incisor was teased back into the arch form with elastic thread. A localized gingivectomy was performed on the lateral incisor to remove the excessive labial gingiva before a bracket was placed, and the tooth was engaged with the archwire. The bracket used on the lateral incisor was placed upside down (8 ) to affect labial root torque. Class II elastics, anterior box elastics (both 0.25-in, 4 oz), and interproximal reduction of the mandibular incisors were used to idealize the occlusion. The nal 8 months of treatment were used to effect as much labial root torque on tooth 22 as possible to match the inclination of the contralateral lateral incisor. After 43 months of treatment, the appliances were removed, the nal records were taken, and a xed lingual retainer was placed canine-to-canine in the mandibular arch (Figs 10-13). An Essix-type retainer for daytime use and a Hawley retainer for nighttime use were given for retention of the maxillary arch.
TREATMENT RESULTS

Fig 5. Radiographs after leveling the occlusal arch.

The transposition was fully resolved, and ideal Class I molar and canine relationships were achieved. Ideal overjet and overbite were achieved with adequate canine disclusion and protrusive guidance. Cephalometric analysis showed that a Class III growth pattern had occurred during the treatment, with significant mandibular growth (both vertically and horizontally) and no maxillary change (Figs 13 and 14, Table). Cast and cephalometric analysis showed that the crowding was resolved in 2 ways: through lateral arch expansion and proclination of the incisors. The mandibular molars expanded by 4 mm, the mandibular rst premolars expanded by 4 mm, the maxillary rst molars expanded by 6 mm, and the maxillary rst premolars expanded by 8 mm. However, the mandibular canines showed no expansion, considered important for long-term stability. The mandibular

incisors proclined 5 to 96 , but stayed within a standard deviation from a normal value of 92 . The maxillary incisors, however, changed inclination by 112.5 . The composite tracing demonstrates that the changes in maxillary inclination were both labial crown tipping and palatal root torque. It makes sense that the maxillary incisors had to be proclined labially to maintain a positive overjet as the mandible grew at a faster pace than the maxilla. The composite tracings show no negative change in her soft-tissue prole with some straightening of the prole as her mandible grew forward. This was a goal of both the parents and the clinician. The gingival margins of the maxillary anterior teeth were not ideal but could be idealized with a minimally invasive gingivectomy procedure. There also appeared to be mild canting of the occlusal plane in the nal result, not uncommon in patients with unilateral canine impactions. Despite the effort and subsequent success to upright the maxillary left lateral incisor with labial root torque, the maxillary rst premolars were nished with too much buccal crown tip. The nal panoramic radiograph demonstrates ideal root alignment except for the maxillary left lateral incisor, which was angulated distally (Fig 12). Because of a discrepancy between the long axes of the root and the crown, the clinical crown appears well aligned in her smile. About 2.5 mm of root resorption was noted on the tip of the maxillary left lateral incisor (18%). No root resorption was noted on the CBCT scan after the crown of this tooth was tipped back into the palate. The root resorption most likely occurred as heavy labial

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Fig 6. The CBCT scan showed a complete transposition, with the crown of the canine positioned buccally to the root of the lateral incisor but palatally to the crown of the lateral incisor.

Fig 7. A palatal bar with soldered hooks and buttons was placed on the crown of the lateral incisor and activated with a power chain.

root torque was being expressed during the last 8 months of treatment. After 9 months, the patient returned, and the retention photos were taken, demonstrating good stability of the nal result (Fig 15).
DISCUSSION

This patient presented with a challenging case of unilateral transposition of the left lateral incisor and canine. The transposition was complete, with both the crown and the root of the canine mesial to the crown and the root of the lateral incisor. The case was further complicated because the canine was unerupted, and conventional radiographs offered conicting evidence of its relative position to the lateral incisor. Other reported cases of Mx.C.I2 transposition had initial presentations with the canine fully erupted labially in the arch form.1,2 Orthodontic mechanics are certainly easier to conceive when all affected teeth can be absolutely localized. Complete transpositions require complex and often protracted treatment plans with no guarantee of success. Parker20 suggested that heroic efforts to resolve transpositions can be disappointing. Therefore, careful consideration must be given to the specic circumstances of the patient, including predicted compliance and

tolerance of protracted treatment, before embarking on a heroic treatment plan. The ultimate success of the treatment plan hinged on accurate assessment of the relative positions of the transposed teeth. Conventional radiography in this case gave conicting viewpoints. Ericson and Kurol21 reported that, in a sample of Swedish children, assessment using conventional periapical radiography was only 80% successful in the localization of ectopic canines. The other 20% required tomography for accurate localization. The conventional periapical assessments were least successful in patients whose canine overlapped the lateral incisor (similar to this case report). There have been reports of successful use of computerized tomography (CT) in the localization of impacted canines.22 Although useful for elucidating the exact location of the impacted tooth, the cost to the patient is often prohibitive. The amount of radiation exposure is also an argument against the routine use of medical CT scans for localization of impacted teeth. However, the value of CT scans was evident in these reports. Ericson and Kurol21 reported that CT can detect 50% more cases of resorption than periapical and panoramic radiography. They also stated that, when clinicians were given the additional information from a CT scan, they changed their treatment plan 43% of the time.

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Fig 8. A second CBCT scan showed complete separation of the lateral incisor root and the canine crown. A path had been cleared for surgical exposure and traction of the canine. No root resorption was noted on the lateral incisor.

Fig 9. A, The canine was brought into the arch with light 0.014-in NiTi wire; B, the arch form was stabilized with a stainless steel overlay arch (0.016 3 0.025 in); C, the lateral incisor was teased back into the arch form with elastic thread; D, a localized gingivectomy was performed on the lateral incisor to remove the excessive labial gingiva, and a bracket was then placed and the tooth engaged with the archwire.

Today, we have the ability to gather undistorted, accurate 3-dimensional views of the jaws with CBCT at a cost that is not prohibitive and at a radiation dose that is considerably less than that of conventional medical CT. The problem with panoramic images is that they are magnied and distorted. Distortion is the unequal magnication of different parts of the same image. Panoramic distortion makes it unreliable for making measurements.23 Panoramic and periapical radiography provide only 2-dimensional images, whereas CBCT can provide buccolingual, axial, coronal, sagittal, and panoramic views. And, with the use of software, these images

can be easily converted into accurate 3-dimensional images and videos. Panoramic and periapical lms in this case report could not provide an accurate assessment of the relative positions of the transposed teeth. They also could not provide an accurate assessment of whether the lateral incisor suffered any root resorption as the canine erupted ectopically. Ericson and Kurol24 reported that CT scanning substantially increased the detection of root resorption on incisors adjacent to ectopically erupting maxillary canines. The sensitivity of intraoral (periapical) lms was low when diagnosing the resorptions.

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Fig 10. Posttreatement photographs.

Any signs of pretreatment root resorption (especially midroot and into the pulp canal) would have swayed my treatment plan to extraction of the affected lateral incisor and an eventual implant-supported crown restoration. The necessity of moving the lateral incisor palatally has been discussed before.2,13 Doing so in this patient avoided potential root interferences and prevented potential loss of the cortical plate by allowing the canine to erupt into the arch rather than too far labially. The second CBCT scan conrmed the root separation, so that the treatment plan could proceed with condence. Once space was gained for the lateral incisor, it was necessary to bring it into the arch form. Effecting significant labial root torque through archwire manipulation and bracket placement (upside down to effect 8 of torque) was the thrust of the nal 8 months of treatment. The nal result demonstrated mild root resorption (2.5 mm, 18%) on the maxillary left lateral incisor that should have no long-term consequences with regard to loss of tooth vitality or tooth mobility. Kokich25

dened moderate to severe root resorption as greater than a 20% reduction in the original root length. Several authors have looked at the long-term consequences of orthodontically induced apical root resorption. Some evidence suggests that orthodontically induced root resorption does not progress once the appliances are removed.26,27 Falahat et al28 demonstrated a favorable long-term prognosis in a long-term follow-up (2-10 years) of resorbed maxillary incisors. Of 32 teeth in the study, 13 had repair of the resorption lacunae, 12 remained unchanged, and 7 had increased root resorption. However, of the 7 incisors with increased resorption, none lost vitality or exhibited ankylosis. Jonsson et al29 demonstrated that postorthodontic root resorption remained stable up to 25 years after treatment, if the roots were at least 10 mm in length and had a healthy periodontium. Despite the difculty of planning the treatment for this patient, the protracted treatment time, and the additional costs of imaging, the nal result was gratifying for the clinician, the patient, and the patients family.

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Fig 11. Posttreatement dental casts.

Fig 13. Posttreatment cephalometric tracing. CONCLUSIONS

Fig 12. Posttreatment radiographs.

Complete resolution of a transposed lateral incisor and a canine is a unique challenge for an orthodontist. Careful consideration of the relative positions of the

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Fig 14. Cephalometric analysis showed that a Class III growth pattern had occurred during the treatment, with signicant mandibular growth (both vertically and horizontally) and no maxillary change.

Fig 15. Nine months postretention.

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transposed teeth is imperative for developing a plan that will minimize the likelihood of negative treatment consequences (root resorption with subsequent tooth mobility and periodontal issues). This case report demonstrates the difculty of using conventional radiography to adequately assess the relative positions of transposed teeth. CBCT imaging was necessary to condently execute a successful treatment plan that resulted in an esthetic and functional outcome.
REFERENCES 1. Shapira Y, Kuftinec M. Maxillary canine-lateral incisor transpositionorthodontic management. Am J Orthod Dentofacial Orthop 1989;95:439-44. 2. Maia F. Orthodontic correction of a transposed maxillary canine and lateral incisor. Angle Orthod 2000;70:339-48. 3. Yilmaz H, Turkkahraman H, Sain M. Prevalence of tooth transpositions and associated dental anomalies in a Turkish population. Dentomaxillofac Radiol 2005;34:32-5. 4. Burnett SE. Prevalence of maxillary canine-rst premolar transposition in a composite African sample. Angle Orthod 1999;69:187-9. 5. Ruprecht A, Batniji S, El-Neweihi E. The incidence of transposition of teeth in dental patients. J Pedod 1985;9:244-9. 6. Ely N, Sherrif M, Cobourne M. Dental transposition as a disorder of genetic origin. Eur J Orthod 2006;28:145-51. 7. Plunkett DJ, Dysart PS, Kardos TB, Herbison GP. A study of transposed canines in a sample of orthodontic patients. Br J Orthod 1998;25:203-8. 8. Peck S, Peck L. Classication of maxillary tooth transpositions. Am J Orthod Dentofacial Orthop 1995;107:505-17. 9. Shapira Y, Kuftinec M. Maxillary tooth transpositions: characteristic features and accompanying dental anomalies. Am J Orthod Dentofacial Orthop 2001;119:127-34. 10. Peck L, Peck S, Attia Y. Maxillary canine-rst premolar transposition, associated dental anomalies and genetic basis. Angle Orthod 1993;63:99-109. 11. Camilleri S. Maxillary canine anomalies and tooth agenesis. Eur J Orthod 2005;27:450-6. 12. Newman GV. Transposition: orthodontic treatment. J Am Dent Assoc 1977;94:544-7.

13. Shapira Y, Kuftinec M. Tooth transpositionsa review of the literature and treatment considerations. Angle Orthod 1989;59:271-6. 14. Bracco P, Titolo C, Zaretta L, Moretti A, Debernardi C. Orthodontic treatment in a bilateral lateral incisor-canine transposition. Minerva Ortognatod 2004;22:61-5. 15. Peck S, Peck L, Kataja M. Concomitant occurrence of canine malposition and tooth agenesis: evidence of orofacial genetic elds. Am J Orthod Dentofacial Orthop 2002;122:657-60. 16. Goyenc Y, Karaman A, Gokalp A. Unusual ectopic eruption of maxillary canines. J Clin Orthod 1995;29:580-2. 17. Shapira Y, Kuftinec M. A unique treatment approach for maxillary canine-lateral incisor transposition. Am J Orthod Dentofacial Orthop 2001;199:540-5. 18. Halazonetis D. Horizontally impacted maxillary premolar and bilateral canine transposition. Am J Orthod Dentofacial Orthop 2009;135:380-9. 19. Goaz P, White S. Oral radiology. 2nd ed. St Louis: C. V. Mosby; 1987. p. 120. 20. Parker W. Transposed premolars, canines, and lateral incisors. Am J Orthod Dentofacial Orthop 1990;97:431-8. 21. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofacial Orthop 1987;91: 483-92. 22. Schmuth GP, Freisfeld OK, Schuller H. The application of computerized tomography (CT) in cases of impacted maxillary canines. Eur J Orthod 1992;14:296-301. 23. Serman NJ. Pitfalls of panoramic radiology in implant surgery. Ann Dent 1989;48:13-6. 24. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000;70:415-23. 25. Kokich V. Orthodontic and nonorthodontic root resorption: their impact on clinical dental practice. J Dent Educ 2008;72:895-902. 26. Remington DN, Joondeph DR,  Artun J, Riedel RA, Chapko MK. Long-term evaluation of root resorption occurring during orthodontic movement. Am J Orthod Dentofacial Orthop 1989;96:43-6. 27. Copeland S, Green LJ. Root resorption in maxillary central incisors following active orthodontic treatment. Am J Orthod 1986;89:51-5. 28. Falahat B, Ericson S, DAmico RM, Bjerklin K. Incisor root resorption due to ectopic maxillary canines. Angle Orthod 2007;78: 778-85. 29. Jonsson A, Malmgren O, Levander E. Long-term follow-up of tooth mobility in maxillary incisors with orthodontically induced apical root resorption. Eur J Orthod 2007;29:482-7.

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