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Percentiles relative to maxillary permanent canine inclination by age: A radiologic study

Giulio Alessandri Bonetti, Matteo Zanarini, Margherita Danesi, Serena Incerti Parenti, and Maria Rosaria Gatto Bologna, Italy

Introduction: Few studies have investigated developmental norms for maxillary permanent canine eruption. In this observational cross-sectional study, we aimed to provide an age-related description of the percentiles relative to canine inclination in a large sample of nonorthodontic patients. Associations between inclination and sector were also analyzed. Methods: Canine inclination and sector location were measured on 1020 panoramic radiographs obtained from subjects of white ancestry aged between 8 and 11 years not seeking orthodontic treatment. The total sample comprised 2037 canines. Results: Canine inclination increases between 8 and 9 years and decreases between 9 and 11 years. The greatest value for each percentile is at 9 years. A linear model should be hypothesized for differences in canine inclination between 2 successive ages in correspondence to each percentile. The proportion of sector 2 canines decreases and that of sector 1 increases with age. In the same age group, the inclination generally decreases as the sector decreases. Conclusions: Percentiles by age show the average canine inclination in a certain population. Further studies are required to verify whether percentiles can be a diagnostic aid for determining normal canine inclination at a given age and for quantifying the risk of canine impaction or adjacent root resorption. Read the full text online at: www.ajodo.org, pages 486.e1-486.e6.

EDITORS SUMMARY

Am J Orthod Dentofacial Orthop 2009;136:486-7. 0889-5406/$36.00 Copyright 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2009.04.012

Because I had a palatally impacted maxillary canine as a child, I was concerned that one of my children might have a similar problem. I regularly took radiographs of their developing canines, but I still was not sure whether they would become impacted until they reached adolescence. Sure enough, 2 of my 3 children developed palatally impacted canines requiring surgical exposure and lengthy orthodontic treatment. Would access to the information from these authors in Bologna, Italy, have helped me? As part of a large cross-sectional study, these researchers developed an age-related description of the percentiles relative to canine inclination in white nonorthodontic patients, ages 8 to 11 years old. Their thinking was similar to mine in observing children as they matured. An understanding of the normal path of canine eruption should therefore be of critical interest to a clinician hoping for early detection of canine impaction for which preventive measures could be used. Few studies have tried to determine the normal pattern of maxillary canine eruption for different age groups. To gather the sample, patients referred for panoramic radiographs over several years from a general pediatric population were included. The study sample comprised 1020 subjects with a total of 2037 permanent maxillary canines. The results clearly indicate that the maxillary canines show an initial increase in mesial inclination between 8 and 9 years of age, followed by a decrease between 9 and 11 years, with the maximum value for each percentile at 9 years of age. There was considerable individual variability in this study, as in other similar studies. To explore the possibilities of using data like these to help diagnose my childrens eruption problems, I might have had more success by analyzing the differences in inclination of the canines between 2 successive ages as they corresponded to each percentile, thus providing a linear model for such variations. These data will provide greater benet to patients once validated by additional studies.

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American Journal of Orthodontics and Dentofacial Orthopedics Volume 136, Number 4

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Q&A Editor: Did you gather family histories for these children, or did you have only the radiographs to evaluate? Alessandri Bonetti: We were dealing with patients in the mixed dentition stage referred to the Department of Radiology for a routine panoramic radiograph. We started to observe and collect radiographs based on the absence of the following: previous orthodontic treatment, trauma, agenesis, odontomas, cysts or supernumerary teeth in the study zone, small or peg-shaped maxillary lateral incisors, craniofacial syndromes, and cleft lip or palate (or both). We mainly focused on local factors that might have affected the eruptive positioning of the maxillary permanent canine. Any eventual inherited tendency for ectopic canines was not controlled for. If proven in future studies, the percentiles described in our research could be an effective tool for clinicians in clinical decisionseg, more frequent checkups for borderline patients. If aberrant eruptive positioning of the canine is identied, regardless of hereditary factors, its correction with preventive measures should be considered to improve the local condition for its uneventful eruption. However, systemic factors such as those from family histories could provide additional information or, otherwise, additional indications for more frequent check-ups. Editor: With such a large sample, do you think you overcame much of the bias in the sample by examining only those who were referred after getting the panoramic radiograph? Alessandri Bonetti: We tried to do that. Because of the high variability of the data relative to the average canine inclination reported in the previous study by Fernandez et al (1998), our purpose was to obtain a larger sample of subjects to minimize the effects of such variability, which limits the capacity to precisely predict canine inclination at a given age. This observational study gave us the only chance to work on a large scale. Furthermore, low variations between the interquartile range found in this study show minor variability in the data.

The results of this study represent a certain populationwhite patients in northern Italy referred to the Department of Oral Sciences of the University of Bologna; they were screened and do not represent the developmental norm in general. Further validation is required to determine the percentiles clinical effectiveness. However, our results agree with what Fernandez et al (Eruption of the permanent upper canine: a radiologic study. Am J Orthod Dentofacial Orthop 1998;113:414-20) had previously reported (maximum mesial inclination is reached at approximately 9 years of age, and gradual straightening occurs until emergence is complete). Furthermore, in our subjects, an inclination $25 to the midline coincides with the interval between the 90th and 95th percentiles for each age, suggesting high risk for canines at these percentiles. On the contrary, negative values or near zero values for canine inclination (between 3.68 and 10.50) have been found below the 10th percentile for each age, suggesting low risk for canines at these percentiles. At any rate, further clinical studies are required to identify a percentile cutoff that is clinically signicant, thereby indicating canines with a high risk of impaction or possible detrimental effects, and dening the range of normal variability for each age group in terms of canine inclination. Editor: Do you plan a followup study of this sample to determine how many were actually treated for palatally impacted maxillary canines? Alessandri Bonetti: This observational study led us to set up a new longitudinal study to determine whether tooth impaction or adjacent incisor root resorption will occur for maxillary permanent canines dened as high risk and whether canines not at risk or at low risk will spontaneously and uneventfully erupt. Such a study can give more evidence-based information about the clinical effectiveness of the percentiles elaborated in this research, thereby dening the range of normal variability for each age group in terms of canine inclination.