The Management and 'Fate' of Palatally Ectopic Maxillary Canines
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Enhanced CPD DO C Orthodontics
Leonie Seager
Jinesh Shah and FJ Trevor Burke
The Management and ‘Fate’ of
Palatally Ectopic Maxillary Canines
Abstract: With the exception of third molar teeth, the maxillary canine is the most frequently impacted tooth, with the majority of these
being palatally ectopic. When patients present with impacted canines there can often be several treatment options available to them.
These could include interceptive treatment, exposure and alignment of the canine, extraction of the impacted tooth or acceptance of the
deciduous canine. It is important that treatment decisions determining the ‘fate’ of palatally impacted canines should be taken on a case-
by-case basis.
CPD/Clinical Relevance: The clinician should understand that several options might be available to the patient presenting with a palatally
ectopic maxillary canine, in order to allow an informed choice of treatment.
Dent Update 2020; 47: 153–161
The maxillary canine tooth is usually one of The majority of maxillary However, genetics as a primary
the last teeth of the permanent dentition impacted canines are also ectopic, with aetiological cause of canine impaction
to erupt, normally between the age of literature showing 61% to be palatal and has also been considered4 due to its
11 and 12 years.1 With the exception of 35% buccal to the line of the arch.3 association with not only other dental
third molar teeth, the maxillary canine anomalies, but also the presence of sex
is the most frequently impacted tooth, Aetiology of maxillary palatally differences, population differences and
with a prevalence between 0.2%−2.8%, impacted canines familial occurrences. It is most likely that
affecting female subjects 2.3−3 times more the aetiology of palatally ectopic canines is
The exact aetiology of palatal maxillary
frequently than males.2 multifactorial.
canine ectopia is unknown, although four
It is also important to consider
distinct groupings of causation have been
that buccally impacted canines should
described:2
be described as separate aetiological
1. Local hard tissue obstruction;
Leonie Seager, BDS, MFDS, MSc, entities from palatally impacted canines.
2. Local pathology;
MOrth RCS(Ed), Specialist Orthodontist, Buccal impaction is usually associated
3. Departure from or disturbance of normal
Shrewsbury Orthodontic Centre with inadequate arch space, and eventual
incisor development;
and Royal Stoke University Hospital eruption of the canine will occur once space
4. Genetics.
(email: leonie.seager@uhnm.nhs.uk), is made available. This is in contrast with
It is thought that the strongest
Jinesh Shah, BDS, MFDS RCS(Edin), palatally ectopic canines, which usually
influence for palatal canine impaction
MClinDent(Shef ), MOrth RCS(Edin), occur even in the presence of adequate
relates to local factors. The ‘guidance
FDS(Orth) RCS(Edin), FDS RCS(Eng), arch space, and require surgical treatment
theory’ suggests that the lateral incisor is
Orthodontic Consultant, Royal Stoke and the application of orthodontic traction
an important contributor to canine ectopia
University Hospital and FJ Trevor Burke, for eruption.4
owing to a loss in guidance for the eruption
DDS, BDS, MSc, MGDS RCS(Ed), FDS
path of the canine, which is the longest
RCS(Eng), FFGDP(UK), FADM, Professor
in the dentition, at a distance of 22 mm. Risks and consequences of
of Primary Dental Care, University of
This theory is supported by a significantly canine impaction
Birmingham Dental Hospital, 5 Mill Pool
increased incidence of maxillary canine A palatally impacted canine usually requires
Way, Edgbaston, Birmingham B5 7EG,
impactions in patients with missing, peg- treatment for a variety of reasons, including
UK.
shaped or microdont lateral incisors.2 the avoidance of possible pathological
February 2020 DentalUpdate 153Orthodontics
a canine(s) not be palpable. A favourably
positioned canine is usually palpable buccal
to the resorbing deciduous tooth by the
age of 10−11 years. With regards to this and
further information regarding radiographic
diagnosis, the reader is referred to the
British Orthodontic Society’s document
Managing the Developing Occlusion.6 The
subsequent process of then classifying
the severity of the impaction, once it has
been diagnosed, is also outside the scope
of this article and the reader is directed to
appropriate literature to ensure that they
are proficient in diagnosing and classifying
an impacted ectopic maxillary canine.7
b
Treatment choices
In line with the diagnosis and management
of all patients, a comprehensive history as
well as an examination is necessary upon
patient presentation, as other factors may
well influence the choice of treatment
selected for treating the palatally impacted
canine. Patient factors, such as the desire to
undergo orthodontic treatment, should be
considered as important as dental factors.
Making treatment decisions for
cases with an impacted canine can often
be difficult and, in many cases, several
management options are available to the
patient. On one hand, the desire to align the
Figure 1. Radiographic images demonstrating root resorption of lateral incisor due to an impacted tooth, which is perceived to be important
canine: (a) plain radiograph; (b) part of CBCT image. to both aesthetics and function, should be
weighed against the knowledge that canine
alignment treatment is likely to be time-
consuming and potentially complex.
sequelae such as tooth resorption, cyst Ankylosis of the ectopic canine; There can be several potential
formation and infection. Spacing and centreline shifts. treatment choices available and these
Root resorption of the adjacent Periodic radiographs, due should be presented and discussed with the
lateral incisor as a result of canine impaction to these potential complications, are patient including:
can be considerable, take place rapidly recommended and the patient should Interceptive treatment should the patient
and unpredictably, and with a female be warned of the most common risks present at the appropriate age.
preponderance. Cone Beam Computed regarding the possibility of root resorption No orthodontic or surgical treatment
Tomography (CBCT) studies have shown a to adjacent teeth and cyst formation, and acceptance of the dentition as it was at
48% incidence of root resorption affecting should they choose to leave the tooth in presentation with either:
the lateral incisors,5 a much higher situ.
– Maintenance of the deciduous canine,
percentage than that shown on plain should it still be present, and with the
films. Figure 1 demonstrates a case where Diagnosis understanding that it is likely to be
root resorption of the lateral incisor was The accurate diagnosis of palatally impacted exfoliated in the future;
suspected on plain film and confirmed by canines is obviously crucial before accurate – Acceptance of a gap in the canine region
CBCT. and appropriate treatment planning should spacing be present;
Canine impaction can also result can take place. It is recommended that – A prosthetic replacement if space is
in other negative sequelae such as: palpation of unerupted canines should be available in the canine region.
Migration of the adjacent teeth and loss a key part of a child’s dental examination so Surgical exposure of the canine
of arch length; that appropriate referral to an orthodontist and orthodontic treatment to align it.
Cyst formation; at a suitable age can take place should the This option might need to be taken in
154 DentalUpdate February 2020Orthodontics
gold standard treatment, it can substantially order to increase the effectiveness of the
increase the overall treatment time and intervention, may also be important. As
complexity, with the success of the result with all interceptive treatments, appropriate
being heavily influenced by whether the patient selection in terms of what the
treatment aims were achieved without the patient wants and is able to cope with
occurrence of any damage to the adjacent should also be taken into account. If active
teeth. orthodontic treatment is contra-indicated,
These options will now be or the patient is adamant that he/she would
discussed in further detail in order to assist not be willing to consider fixed appliances
the reader in understanding the different later, then removal of the deciduous canine
options which might be presented to the may also not be ideal, as it may commit
Figure 2. Bilateral closed exposure of impacted patient and why a particular treatment the patient to later active treatment and
canine with ‘piggyback’ mechanics to gold chains remove the treatment option of accepting
choice may have been selected.
demonstrated.
the deciduous canine long term. This
Interceptive management should be borne in mind, particularly if the
permanent canine is diagnosed as being
Interceptive intervention involves the
unfavourably positioned and the deciduous
extraction of the deciduous canine in
canine has a minimally resorbed root and
an appropriate aged patient, also often
thus might be considered of favourable
in combination with space creation
long-term prognosis.
mechanics, such as the use of a fixed
Interceptive extraction of the
appliance, headgear or expansion
deciduous canine undertaken at the correct
appliances such as Rapid Maxillary
time and in the right case should therefore
Expansion (RME) or a Quadhelix.
be considered. It would be recommended
Figure 3. Balista spring mechanics. The impact of these interceptive
that clinicians keep abreast of the literature
approaches in preventing or altering canine
in this area and take into account any
ectopia has been considered in depth and
recommendations made when the latest
the Royal College of Surgeons guidelines
full Cochrane review is published, to ensure
support the practice of extraction of the that they are following evidence-based
deciduous canine in order to try and practice.
change the path of development of the
palatally displaced canine, the aim being
an uneventful eruption of the canine Comprehensive management
into the dental arch.8 The evidence base Alignment of the canine
for this recommendation is low as the Alignment of a palatally ectopic canine
2012 Cochrane Systematic Review on the will usually involve surgical uncovering of
subject judged that there was ‘no reliable the tooth (exposure), followed by the use
evidence with regard to the effects of of fixed appliances to apply traction to the
primary canine extraction’. However, this tooth to ensure its eruption and ultimate
Figure 4. Distalizing mechanics used in a closed
Cochrane review has now been withdrawn alignment within the dental arch. Two
exposure case.
and a new protocol submitted.9 This new techniques are currently in use in the UK:
review will hopefully help further guide 1. Closed exposure − involving surgical
clinicians by combining the findings of uncovering of the tooth, bonding of a
combination with extraction of an adjacent recently published randomized controlled gold eyelet and chain to the tooth and
tooth if there are space requirements studies, building upon the evidence base subsequent re-covering of the tooth and
needed to align the canine. for effective interceptive intervention. These suturing of the mucosa with the tooth
Extraction of the impacted canine and recent studies have demonstrated a 40% being moved into position covered by
orthodontic movement of the first premolar reduction in canine impaction when the the palatal mucosa by the use of various
into its position. deciduous canine was extracted,10 although mechanics such as ‘piggybacks’ (Figure 2)
Extraction of the impacted canine variability in whether the permanent canine and/or ballista springs (Figure 3). Distalizing
and acceptance of a gap or prosthetic subsequently spontaneously erupted was mechanics may also be used first to ensure
replacement of the canine if there is space high and the importance of the interception that the crown of the impacted canine is
within the arch. taking place when the patient is between away from the lateral incisor root prior to
Autotransplantation of the canine. 10 and 11 years old is emphasized.11 The attempting orthodontic alignment (Figure
Whilst surgical exposure and alignment criteria of subsequently ensuring that space 4).
of a palatally impacted canine is usually is created within the arch, in combination 2. Open exposure − involving removal of
possible, and is widely considered to be the with extraction of the deciduous canine in the overlying palatal mucosa so that the
156 DentalUpdate February 2020Orthodontics
Figure 5. An example of a bilateral open
exposure case.
a
Figure 8. OPG radiograph of a case where it was decided to retain the URC and extract the impacted
UR3.
presenting with palatally ectopic canines
is now being challenged, especially in the
b light of demands for quicker treatment
times, reduced treatment risks and
Figure 9. Post-treatment image demonstrating balancing resource efficiency with patient-
bilateral premolar substitution for canines. centred outcomes.
The generally perceived
benefit of aligning an impacted canine
tooth is that a more acceptable occlusal
same mechanics as those used in closed result is achieved (ie canine guidance or
exposure cases (Figure 5). mutually protective occlusion rather than
Figure 6. (a). Pre-treatment image showing the
A recent Cochrane review12 group function), as well as optimizing
retained ULC in situ. (b) Post-treatment image consolidated the evidence base comparing the aesthetic result in terms of achieving
following alignment of palatally impacted UL3. the two techniques and concluded that dental symmetry, proportions of the upper
currently ‘the evidence suggested that anterior dentition and an ideal emergence
neither open nor closed surgical technique profile. The canine tooth is also arguably a
for exposing palatally displaced maxillary desirable tooth to have functioning within
canine teeth is superior’. However, the the arch, as it is often seen to be one of the
evidence included in the review was last-standing teeth in the partially dentate
described as being at high risk of bias. The when all others have failed.
review highlights that several ongoing Despite canine alignment
clinical trials have been identified and usually being considered as the preferred
will hopefully add to the evidence base treatment choice by the orthodontic
in the future. Exposure and alignment of profession, adverse outcomes have been
Figure 7. Post-treatment image demonstrating
the impacted canine is considered to be reported following orthodontic treatment
aesthetic differences between a previously the gold standard choice in the UK at this to align an impacted maxillary canine.
palatally impacted UR3 and the contralateral time and, whilst much of the evidence These include differences in tooth colour,
canine which erupted uneventfully without underlying this treatment choice is derived alignment, vitality of the canine tooth,
orthodontic assistance. from case reports,8 clinical experience probing pocket depth, crestal bone and
demands a respect for the excellent results gingival margin height,13 as well as aesthetic
that can be achieved by the surgical differences between a previously palatally
exposure and orthodontic alignment of a impacted canine, which had been aligned,
tooth is visible. The orthodontist then palatally impacted maxillary canine (Figures and its contralateral partner, which had
bonds an attachment directly onto the 6a and b). Nevertheless, the view of this followed a normal path of eruption.14
tooth and is able to visualize the tooth as it treatment being the ‘gold standard’ to be This is demonstrated in Figure 7 where
is moved into position, often utilizing the undertaken in the majority of patients obvious torque discrepancies are evident
February 2020 DentalUpdate 157Orthodontics
post-treatment. However, there is also no term prognosis of a deciduous canine of choice and, with a 10-year survival
evidence available which reports on the would be poor, regardless of its root length of 65%, it should be anticipated
cosmetic importance of the canine and or aesthetic acceptability of its crown.17 that the patient may require several
whether these findings have any effect on This view, however, is increasingly being replacements during his/her life-time,
the patient’s satisfaction with treatment challenged and many dental professionals depending on the patient’s age at the
outcome. have encountered patients where time when the deciduous canine is
Aligning a palatally ectopic deciduous canines have been successfully lost.19 A minimally invasive, cantilevered
canine will also add time onto the expected retained for several decades in terms design appears to be the bridge design
length of average orthodontic treatment, of function and aesthetics. Therefore, demonstrating the lowest clinical failure
with treatment expected to take at least although literature confirming how long rate.20
2−3 years from initial bond-up to brace a deciduous tooth can be expected to
removal. This can be further compounded survive, its acceptability to patients, as well
the more unfavourably the canine is as its impact on function is scarce, it can still Gaps
positioned, as well as by an advancing be worthwhile to consider this treatment Should the patient’s deciduous canine
patient’s age.15 This may increase the risks approach.18 be subsequently lost, he/she may also
associated with orthodontic treatment There is also no evidence choose to accept a gap in the canine
as well as testing patient co-operation regarding how the retention of a deciduous region. Although there are no studies
and compliance, and the patient may canine may affect the aesthetics of the that have specifically examined the
demand that the brace is removed before smile. The deciduous canine crown, in impact of a gap in the canine area,
the orthodontist is wholly satisfied with comparison to its permanent successor, is since the canine tooth is positioned in
the canine’s position and/or torque. The smaller in size but also lighter in colour. It the aesthetic zone, it can be postulated
presence of a canine-guided occlusion is also likely to display an element of wear, that it will have a significant impact on
has also not been shown in the literature although often if the deciduous canine lacks the patient’s aesthetic concerns and a
to confer any great advantage over wear and exhibits a good size in relation prosthesis to fill a gap will most likely be
functional occlusion,16 despite it being the to the permanent incisors, its presence requested if an anterior tooth is missing.
popular choice and treatment aim for both may not be obvious at the patient’s dental Results of previous research
orthodontists and prosthodontists. check-up. This can sometimes contribute have indicated that edentulousness can
to a late diagnosis of a palatally ectopic have serious negative psychological and
Other possible treatment permanent canine tooth. social quality of life implications, and
options One benefit of retaining the it may therefore be a fair extrapolation
deciduous canine, especially if the root and that any missing maxillary tooth of the
Alternative options to the alignment of a
coronal structure, as well as its function and anterior segment may have a similar
palatally ectopic canine include accepting
aesthetics, are acceptable, is that, as well impact,21 although the replacement
the shape/size of the deciduous canine, if
as minimal maintenance being required, of these teeth with prostheses such as
still present (or bonding resin composites
bone and soft tissue architecture will be implants can subsequently improve
to it to alter its appearance if space allows),
preserved. Figure 8 shows an OPG in a case psychosocial health.22 Therefore, it is
accepting any residual spacing present, or
where it was decided to retain the URC and highly likely that most patients would
substituting the first premolar tooth for
extract the palatally impacted UR3. The OPG be unwilling to accept spacing in the
the canine. Possible reasons for selecting
indicates a poor prognosis of alignment canine region.
an alternative treatment option to canine
for UR3 as well as excellent root structure
exposure and alignment could include:
to the URC, which hopefully will correlate
The wish to avoid the occurrence of
to intra-oral longevity. Should an aesthetic Premolar substitution
complications or reduce treatment time; An alternative option of premolar
improvement be required to the deciduous
An unfavourable position of the impacted substitution may seem particularly
canine, this can be easily achieved with
canine tooth; attractive when extractions would
composite additions.18 The patient should
Suspected ankylosis of the impacted
be warned that, when the primary otherwise be required in order to make
canine tooth;
tooth fails, it is likely that there may be space for the subsequent alignment of
A severe arch length discrepancy where
insufficient space for an ideal-size prosthetic the canine, as in a situation where the
the first premolar has almost completely
replacement, as the deciduous canine patient presents with severe arch-length
replaced the unerupted canine and
is notably smaller than its permanent discrepancy and the first premolar has
therefore extraction of a unit would be
counterpart (Figures 6a and b). almost completely replaced the position
required in order to align the impacted
The patient may also be of the unerupted canine. In addition to
canine anyway.
restricted in what prosthesis can be a shorter treatment time, there is also
supplied in the future, as it is likely that no current evidence that the alignment
Retention of the deciduous inadequate bone or space will be available of a canine over its substitution by
canine for a dental implant. A resin-bonded bridge a premolar for the sole purpose of
It is commonly considered that the long- is therefore likely to be the restoration attaining canine guidance leads to
158 DentalUpdate February 2020Orthodontics
improved function. Indeed, research has finding has potentially important 3. Stivaros N, Mandall N. Radiographic
shown that there is no increased risk of ramifications as the smile aesthetics is factors affecting the management of
temporomandibular joint disorder in often a primary motivating factor to impacted upper permanent canines.
cases presenting with missing lateral those seeking orthodontic treatment. J Orthod 2000; 27: 169−173.
incisors where space has been closed However, whilst premolar substitution 4. Peck S, Peck L, Kataja M. The palatally
and first premolars substitute for might therefore seem like a good displaced canine as a dental anomaly
canines.23 option in terms of smile aesthetics, of genetic origin. Angle Orthod 1994;
One of the reasons why research into the long-term survivability 64: 249−256.
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might successfully be substituted for position is non-existent. This knowledge incisors after ectopic eruption of
the canine is that the anatomy of the is arguably vital if the clinician is going maxillary canines. A CT study. Angle
premolar crown has a buccal surface to inform the patient about which Orthod 2000; 70: 415−423.
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convexity and cusp shape and therefore functional as well as aesthetic result, and Developing Occlusion: A Guide for
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Conclusion impacted maxillary canine.
therefore describe how the premolar This article has set out to describe Dent Update 2013; 40: 770−777.
can be effectively camouflaged, utilizing some of the options available for the 8. Husain J, Burden D, McSherry P.
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Placing the premolar root more maxillary canine, along with the Palatally Ectopic Maxillary Canine.
buccal in the maxilla to create a canine evidence base behind the ‘success’ of Royal College of Surgeons (Eng),
eminence; these options. The importance of being Faculty of Dental Surgery, 2016.
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A proven barrier membrane1–5
early vascularisation for
superior quality bone1–8
delivers outstanding
clinical performance.9–12
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