British J ournal of Orthodontics/Vol.

25/1998/209216
Introduction
Orthodontics is considered to be a complex problem-
solving domain (Hultgren et al., 1994). A good example of
this is the large number of patient factors and treatment
variables which must be considered when dealing with
maxillary canine ectopia. The complexity of this clinical
problem is further compounded by the scarcity of properly
controlled clinical research. The purpose of this paper is to
review the various treatment options against the available
scientic evidence.
Incidence/Epidemiology
The maxillary canine is second only to the mandibular third
molar in its frequency of impaction. The frequency varies
from less than 08 to 28 per cent (Shah et al., 1978; Grover
and Lorton, 1985). The condition is more than twice as
common in girls (12 per cent) than in boys (05 per cent;
Dachi and Howell, 1961). Canine impaction is found
palatal to a the arch in 85 per cent of cases and labial/buccal
in 15 per cent (Hitchin, 1956; Rayne, 1969; Ericson and
Kurol, 1987b). There is some evidence that patients with
Class I I division 2 malocclusions and tooth aplasia may be
at higher risk to the development of an ectopic canine
(Kettle, 1957; Harzer et al., 1994; Mossey et al., 1994;
Brenchley and Oliver, 1997).
Normal Development and Eruption Pattern
Broadbent (1941) stated that calcication of the permanent
maxillary canine crown starts at 1 year old, between the
roots of the rst primary molar, and is complete at 56
years. By the age of 12 months the crown of the tooth is
found between the roots of the rst primary molar. At 34
years of age the canine passes over the line of the primary
incisors to lie on the labial side of the root of the lateral
incisor (Miller, 1963). At age 4 years the primary rst
molar, the rst premolar germ and the canine lie in vertical
row. Subsequent growth on the facial surface of the maxilla
provides space for the forward movement of the canine so
that its cusp comes to lie medial to the root of the deciduous
canine. Moss (1972) states that the canine remains high in
the maxilla just above the root of the lateral incisor until the
crown is calcied. I t then erupts along the distal aspect of
the lateral incisor resulting in closure of the physiological
diastema if present and the correction of the so called Ugly
Duckling dentition (Kurol et al., 1997).
I n a recent paper, Coulter and Richardson (1997)
quantied the movements of the maxillary canine in three
dimensions using lateral and posteroanterior cephalo-
metric radiographs from the Belfast Growth Study taken
annually between 5 and 15 years of age. I t was shown that
the canine travels almost 22 mm during that time. I n the
lateral plane the canines showed a signicant movement in
a buccal direction between 10 and 12 years of age. Before
this age the movement was in a palatal direction. About
three-quarters of the root is formed before eruption and
root formation is complete 2 years after eruption. Hurme
(1949) stated that gingival emergence of the maxillary
canine after 123 years in girls and 131 years for boys was
late. Thilander and Jacobsson (1968) regarded 139 years
for girls and 146 years as very late for boys as by this time
95 per cent should have erupted. The maxillary canine is
the last tooth to erupt in the upper arch with a deciduous
predecessor and, therefore, is most susceptible to environ-
mental inuences such as crowding.
Aetiology of the Ectopic Canine
The aetiology of the ectopic canine is obscure, but probably
multifactorial. The maxillary canine has the longest path of
eruption in the permanent dentition and this may be a
factor in the aetiology (Coulter and Richardson, 1997).
Arch length discrepancy (crowding and spacing) is
implicated in the aetiology of the ectopic canine. A space
deciency may result in the tooth erupting buccally or its
impaction (Jacoby, 1983). Thilander and Jacobsson (1968)
stated that crowding may be a factor in labial impaction,
but not in palatal impaction. Jacoby (1983) found that in 85
per cent of cases where the canine erupted palatally in his
study that adequate space was present in the arch. He
The Ectopic Maxillary Canine: A Review
P A T R I C K F. M C S H E R R Y B.A ., B.D E N T.S C., M.S C. (L O N D.U N I V ), F.D .S.O R T H (R .C.S.E D. ) ,M.O R T H .
(R .C.S.E D), M.D E N T.S C. (U N I V . D U B.), F.F.D. (R .C.S.I . )
Department of Orthodontics, School of Dentistry, Royal Group of Hospitals and Dental Hospital, Grosvenor Road, Belfast BT12 6BP, UK
I ndex words: Ectopic Canine, Review.
0301-228X/98/003000+00$02.00 1998 British Orthodontic Society
Review Article
Abstract. This article reviews the aetiology and management of the ectopic maxillary canine. Much controversy surrounds
the causes of canine palatal ectopia. The recent evidence surrounding the genetic and guidance theories are examined. The
management options are detailed and the indications for each treatment modality based on the available scientic evidence
are presented. Finally, the untoward sequelae of canine ectopia are discussed.
210 P. F. McSherry Scientic Section BJ O Vol 25 No. 3
suggested that a possible explanation for canine impaction
to be excessive space in the canine area. Other suggested
causes of palatal impaction are trauma to the maxillary
anterior region at an early stage of development (Brin et al.,
1993).
Studies have shown that there is a higher incidence of
palatally ectopic canines in cases with peg shaped small
lateral incisors or in cases with missing lateral incisors
(Becker et al., 1984). The Guidance Theory in its simplest
form regards the distal aspect of the lateral incisor root as
the guide to allow the canine to erupt safely into position. I f
the lateral incisor is anomalous or missing this guidance is
missing resulting in palatal displacement of the canine.
Becker et al. (1981) found a 55 per cent rate of congenital
absence of lateral incisors in a large group of patients with
palatal canines. This was 24 times the rate in the general
population. I t was hypothesized that the lateral incisor was
not sufciently developed at the time when its root would
be most important for guidance of the canine. Oliver et al.
(1989) found that lateral incisors on the side of canine
impaction were generally smaller than on the non impacted
side in a sample of 31 Causacian subjects. Other studies
could demonstrate no or a weak association between
anomalous lateral incisors and canine impaction (Mossey et
al., 1994; Brenchley and Oliver, 1997).
Delayed exfoliation of the primary canine may result in
continued palatal movement of the permanent successor.
However, Thilander and Jacobsson (1968) considered this
persistence of a primary canine to be a consequence rather
than a cause of impaction. Other possible causes include
pathological lesions, ankylosis, odontomes, or super-
numerary teeth. There may also be a higher incidence of
impaction of the maxillary canine following alveolar bone
grafting in patients with cleft lip and palate (Semb and
Schartz, 1997).
A genetic or familial trend has been pointed out by some
workers. Zilbermann et al.(1990) found that the relatives of
patients with palatal canines are likely to exhibit palatally
displaced canines, anomalous lateral incisors and late
developing dentitions. Bjerklin et al. (1992) found that
ectopic eruption of maxillary canines occurs in a higher
frequency than normal in children with other eruption
disturbances such as ectopic rst permanent molars and
concluded that the aetiology was presumably hereditary. A
genetic basis has been suggested by Peck et al. (1994). They
reviewed the evidence regarding the palatally displaced
canine as a dental anomaly of genetic origin concluding that
palatally displaced canines appear to be a product of poly-
genic, multifactorial inheritance. Pirinen et al. (1996)
concluded from their study on 106 consecutive patients
with displaced canines having examined the 1st degree
relatives and the 2nd degree relatives that palatal displace-
ment of the canine is both genetic and related to genetic
incisor-premolar hypodontia and peg-shaped lateral
incisors. Hypodontia was noted in 1920 per cent of 1st /2nd
degree relatives and this was 25 times the population
prevalence. The prevalence of palatally displaced canines
was 49 per cent (also 25 times the population prevalence).
McSherry and Richardson (in press) quantied the move-
ments of the 20 ectopic palatal maxillary canines in three
dimensions using lateral and posteroanterior cephalo-
metric radiographs from the Belfast Growth Study taken
annually between 5 and 15 years of age. I n comparison to
the normal eruption, the ectopic canine always travelled in
a palatal direction and failed to demonstrate the late buccal
movement which normally occurs at age 1012 years.
Treatment Planning Considerations
The ectopic maxillary canine can often require complex
multidisciplinary treatment involving oral surgical,
restorative, periodontic, as well as orthodontic components
(Bishara, 1994).
Management Options
The patient with an impacted maxillary canine initially
must undergo a comprehensive assessment of the maloc-
clusion to localize the canine and decide on its prognosis for
alignment. Factors affecting the prognosis include patient
co-operation, age, general oral health, skeletal variation,
and presence of spacing or crowding in the arch (McSherry,
1996). Other conditions to be taken into account are the
position of the canine in the three planes of space and
whether any resorption of the incisor roots has taken place.
I t is important that the specialist be vigilant with respect to
the malposition of the maxillary canine especially during its
development and be conversant with the normal eruption
pattern. I nterceptive measures, when appropriate, are most
advantageous in terms of cost benet than other more
invasive procedures. Patient and parent counselling on the
treatment options and informed consent is essential to
avoid any medicolegal problems (Machen, 1989).
The treatment alternatives include:
I nterceptive treatment.
Surgical exposure and orthodontic alignment.
Other options.
Interceptive Treatment by Extraction of the Deciduous
Canine
Ericson and Kurol (1988a) carried out an extensive
prospective longitudinal study on a preselected group of
1013 year old children (mean age 114 years) with palatally
ectopic canines and uncrowded arches. They found that 78
per cent of the canines reverted to a normal path of
eruption following extraction of the primary canine. The
percentage improvement depended on the degree of
overlap of the canine over the lateral incisor root and
varied between 64 and 91 per cent. An improvement was
seen in 50 per cent of the successful cases after 6 months. I f
no improvement was seen after 12 months then none could
be expected. No control group was used in this study as the
authors considered it to be unethical and the presence or
absence of the lateral incisor was not specically
mentioned. Power and Short (1993) assessed the effect of
removal of primary canines on the subsequent eruption of
the successor. They found that the success rate was lower at
62 per cent, but a further 19 per cent showed some
improvement. The results showed that the presence of
crowding inhibits eruption of the permanent canine. The
horizontal overlap of the canine over the nearest incisor
was found to be the most signicant factor. I f this exceeded
BJ O August 1998 Scientic Section Ectopic Maxillary Canine 211
half the tooth width then success was unlikely. Both studies
would seem to suggest that if the patient was over 13 years
of age that alternative treatment options should be con-
sidered.
Based on the results of these studies it would seem
appropriate to recommend the extraction of the primary
canine as an interceptive measure when:
The patient is aged 1013 years.
The maxillary canine is not palpable in its normal
position and radiographic examination conrms palatal
canine ectopia. Removal of the primary canine may
show less favourable results where the permanent
canine is located in a more medial position or when the
patient older than the ideal age group (Kurol et al.,
1997).
I f there is no improvement in canine position within 12
months on the OPG, alternative treatment is indicated.
Clinical re-evaluation and follow-up radiographs should
normally be taken at 6-month intervals (Ericson and
Kurol, 1988a).
The elimination of dental crowding in the arch particularly
in the canine/premolar area can possibly stimulate eruption
into the arch (Kurol et al., 1997). However Kuftinec et al.
(1995) recommend that irreversible decisions such as the
extraction of permanent teeth to allow canine eruption
should be delayed for as long as possible.
Localization of the Maxillary Canine
Localization of the unerupted canine involves inspection,
palpation, and radiographic assessment. The position of the
crown of the lateral incisor can give a clue as to the position
of the crown of the unerupted canine, for example, if the
canine is lying on the labial aspect of the lateral root the
crown may be proclined (Moss, 1972; Bishara et al., 1976).
Often the crown of the unerupted canine can be palpated
either in a buccal position or in a palatal position. Clinicians
should become suspicious of the possibility of canine
ectopia if the canine is not palpable in the buccal sulcus
by the age of 1011 years or if palpation indicates an
asymmetrical eruption pattern. I nspection and palpation in
the canine region is recommended annually from age 8
years (Ericson and Kurol, 1986 a,b).
I t has been suggested that radiographic procedures prior
to the age of 10 years are of little benet. Radiographs are
indicated before 11 years of age if there is an asymmetric
path of eruption as determined by palpation, if the lateral
incisor is late in erupting or is tipped labially, if the lateral
incisor is missing or there is a family history of ectopic
canines. After age 11, radiographs are indicated in all indi-
viduals with unerupted and non-palpable canines (Kurol et
al., 1997). Conventional radiography usually involves
taking a combination of radiographs (peri-apicals, standard
upper anterior occlusal, orthopantomogram) and the use of
the principle of vertical or horizontal parallax. The use of
an orthopantomogram or lateral cephalogram can also
assist in determining the vertical position of the canine. The
use of these radiographs will help to localize the canine in
relation to the dental arch and determine the angulation,
height, and mesiodistal position of the canine (Southall and
Gravely, 1989; Fox et al., 1995). The use of computerized
tomography (CT) to localize canines has been described
(Ericson and Kurol, 1988b; Schmuth et al., 1992). I t is useful
to predict the exact position of the canine, the degree of
crowding, incisor resorption, and the width of the dental
follicle. However, this method is rarely used because of
the high cost of equipment. A new development is the use
of magnetic resonance imaging (MRI ) and scanora-
tomography in the localization of the canine (Kurol et al.,
1997).
Exposure With or Without Orthodontic Traction
The conventional treatment option for impacted canines is
exposure and orthodontic alignment. The prognosis for
alignment is dependent on a number of factors which
include the age of the patient, spacing/crowding and the
vertical, anteroposterior, and transverse position of the
canine crown and root. I f the inclination of the canine in
relation to the midline is greater than 45 degrees then the
prognosis for alignment worsens. The closer the tooth is to
the midline the poorer the prognosis. For successful
alignment, the tooth should not be ankylosed and the root
not be dilacerated (Kurol et al., 1997). The further the
canine needs to be moved then the poorer the prognosis for
a successful outcome. To provide for a stable result it is
essential to obtain a good buccal overlap and correct root
positioning (Zachrisson and Thilander, 1985).
The outcome of surgical exposure and orthodontic align-
ment will depend on a number of factors. As with all
orthodontic treatment co-operation and motivation of the
patient is paramount, and the general dental health should
be excellent since the treatment time in these cases is often
prolonged. I t is generally agreed that the optimal time
for alignment is during adolescence (Altonen and
Myllarniemi, 1976; Galloway and Stirrups, 1989).
Palatal Ectopic Canines
Essentially, there are three methods for exposure and
alignment of the canine (McSherry, 1996).
Open surgical exposure and spontaneous eruption.
Open surgical exposure and packing with subsequent
bonding of an auxiliary.
Closed surgical exposure and bonding of attachment
intra-operatively.
The rst method is probably most useful when the canine
has the correct inclination and will then erupt spon-
taneously. The second option is the exposure of the crown
of the canine with packing. The pack is removed about a
week postoperatively and an attachment bonded with
subsequent traction using a xed appliance. There is some
evidence that the periodontal status may be compromized
(Kohavi et al., 1984; Becker et al., 1996). This evidence is
not convincing and a randomized controlled clinical trial is
ongoing (Burden, personal communication).
The third option is the closed technique. This involves
the reection of a palatal mucoperiosteal ap. An attach-
ment is bonded to the crown of the tooth and an eyelet wire
or gold chain exits through the ap to gain attachment to
the xed appliance for immediate traction. The ability to
gain attachment permits a more conservative approach to
212 P. F. McSherry Scientic Section BJ O Vol 25 No. 3
the exposure (Becker et al., 1996). However, a disad-
vantage of this technique is that if bond failure occurs then
re-exposure is necessary. Becker et al. (1996) suggests the
use of an eyelet bonded in a mid-buccal position on the
crown of the impacted tooth at surgery as these have the
highest success rate.
Biomechanical Considerations
Light forces of the magnitude of 2060 g should be applied
to align the canine (Bishara, 1994; Kuftinec et al., 1995).
Various methods have been described for aligning the
canine and these are described in detail by Hunter (1983),
and Kokich and Matthews (1993). These usually include
the use of xed appliances with a transpalatal bar and/or
headgear to control vertical anchorage. The provision and
maintenance of adequate space in the canine area is
essential. Application of force can be in the form of elastic
or wire traction. Usiskin (1991) described the use of gold
chain bonded to the crown of an unerupted canine to apply
traction to align the tooth. A palatal arch with soldered
hooks attached to apply traction to pull the canine away
from the lateral incisor is described. The use of the Ballista
spring (a wire loop constructed of 0012-inch stainless steel
wire) has been described by Jacoby (1979). Roberts-Harry
and Harradine (1995) described the use of a sectional
approach to maxillary canines using a transpalatal arch for
anchorage. They use a 0017- by 0025-inch TMA sectional
archwire from the rst molar to canine providing a low
force over a long range, which is controllable and remains
stable in the 0022-inch slot. Bennett and McLaughlin
(1997) describe the use of a wound on auxiliary to achieve
rst vertical movement and then lateral movement. I t is
constructed of 0014-inch steel wound on to 0019- by 0025-
inch stainless steel. Orton et al. (1995) describe the use of a
lower removable appliance with soldered hooks on the
cribs. Elastic traction is applied to the canine which has a
gold chain with a hook bonded to the tooth. The vector of
force used to align the canine can be changed to rst move
the canine away from the incisor roots and then vertically
and buccally. Fixed appliances are used to nish the
alignment and create adequate buccal root torque and
overlap. Magnetic forces have been advocated by some
authors to apply force to the ectopic canine for alignment
(Sandler et al., 1989; Darendelilier and Friedli,1994).
Retention Considerations
Becker et al. (1983) evaluated post-treatment alignment in
cases whose treatment was completed. They found spacing
and rotations in 178 per cent of impacted canines and only
in 87 per cent on the control side. Woloshyn et al. (1994)
found in a sample of previously exposed palatally impacted
canines approximately 40 per cent displayed noticeable
relapse and were judged to be intruded, lingually displaced,
mesially rotated an average of 3 years and 7 months post-
treatment. The contralateral untreated side were found to
be 91 per cent normal in appearance. They also found
pulpal obliteration in 21 per cent of impacted canines and
discoloration in 75 per cent of cases post-treatment.
Bennett and McLaughlin (1997) suggest the following to
prevent relapse:
Full correction of torque.
Early correction of rotations.
Circumferential supracrestal berotomy.
Provision of a bonded retainer.
I t would seem appropriate to recommend surgical
exposure and orthodontic alignment when:
The patient is willing to wear orthodontic appliances.
The patient is well motivated and has good general
dental health.
I nterceptive measures are inappropriate (Ericson and
Kurol, 1988a).
The degree of malposition is not too great to preclude
orthodontic alignment. The long axis of the ectopic
canine should not be too horizontal or too oblique. The
closer the crown is to the midline and the root is to the
mid-palatal suture the poorer the prognosis for align-
ment (Kurol et al., 1997)
Any evidence of tooth resorption or other pathology
should be such that it is more desirable to preserve the
canine. For example, where a resorbed lateral incisor
has a very poor prognosis, it may be advantageous to
attempt alignment of a poorly placed canine to replace
the lateral incisor.
Buccally Ectopic Canines
Buccal/labial impaction is much less frequent than palatal
impaction occurring in only 15 per cent of cases (Jacoby,
1983). When a buccally ectopic canine is exposed it is
essential that a closed technique or an apically repositioned
ap be used to preserve the attached gingivae (Vanarsdall
and Corn, 1977; Wong Lee and Wong, 1985). Vermette et
al. (1995) examined the use of the apically repositioned ap
versus the closed technique, and found that the apically
repositioned ap resulted in more unaesthetic sequelae
than the closed technique in maxillary anterior teeth.
No Active Treatment/Leave and Observe
I n some cases it may be preferable to carry out no active
treatment except that of regular radiographic monitoring.
The most frequent complication appears to be follicular
cystic degeneration, although the frequency of this is
unknown. Other odontogenic tumours may arise very
rarely. There may be localized loss of attachment and
marginal breakdown of the adjacent teeth, which may
necessitate the removal of the canine and the affected
teeth. There is a need to regularly monitor the unerupted
canine with respect to cystic degeneration, root resorption,
and the other possible complications. I t is not known what
the optimal time interval between radiographs should be to
reduce the radiation dosage for the patient and detect any
lesions which may be arising.
No active treatment could be recommended if:
The patient does not want treatment.
There is no evidence of resorption of adjacent teeth or
other pathology.
I deally, there is a good contact between the lateral
incisor and 1st premolar or good aesthetics/prognosis
for the deciduous canine.
BJ O August 1998 Scientic Section Ectopic Maxillary Canine 213
There is a severely displaced canine with no evidence of
pathology, particularly if it is remote from the dentition,
provided it is monitored radiographically.
Surgical Removal of Permanent Canine
Surgical removal of the tooth is indicated if there is poor
patient co-operation or poor position for alignment (canine
in an oblique or horizontal position). I deally, there should
be a good lateral incisor/rst premolar contact. I n cases
where the patient is willing to undergo comprehensive
treatment, it is possible to use the rst premolar as a
adequate replacement for the canine by mesiopalatal
rotation and the introduction of buccal root torque.
Grinding of the premolar palatal cusp is also necessary.
Other factors to consider include tooth size discrepancy,
and the difculties in handling unilateral mechanics
(Bishara, 1994). I n a case where the primary canine is left
following extraction of the permanent successor it is not
possible to tell how long the primary canine will remain
intact. Little longitudinal research has been carried out on
this aspect of canine ectopia. I n the event of the primary
canine becoming unsightly or being lost it could be
extracted and replaced by a prosthodontic restoration
whether xed, removable, or osseointegrated implant.
Orthodontic treatment may be required to open space
prior to restoration.
The surgical removal of ectopic canines is recommended
when:
Patient declines active treatment and/or is happy with
appearance.
There is evidence of early resorption of adjacent teeth.
The patient is too old for interception.
There is a good contact between the lateral incisor and
1st premolar or the patient is willing to undergo
orthodontic treatment to substitute the rst premolar
for the canine.
The degree of malposition is too great for surgical
repositioning/transplantation.
Surgical Repositioning/Alignment or Transplantation
The prognosis for autotransplantation of ectopic canines in
adults is poor (Moss, 1974). Periodontal ligament healing
without any root resorption varied between authors from
25 per cent to 85 per cent. At a later stage of development
the root is fully formed and the chances of pulpal and
periodontal healing is reduced (Andreasen 1987; Schatz et
al., 1992). The optimal developmental stage for autotrans-
plantation is when the root is 5075 per cent formed
(Kristerson, 1985). I n light of the good prognosis for auto-
transplantation of premolars documented by Andreasen
(1992) canine transplantation should be planned as early as
possible. The technique is described in detail by Andreasen
(1992). I n a recent paper by Berglund et al.(1996) a method
of exposure and partial alignment was described for
canines in oblique horizontal positions. Atraumatic
removal of these teeth may be difcult. The canine is
pretreated with distal and vertical traction following
exposure in order to facilitate atraumatic removal and
autotransplantation. Of the 21 autotransplantations, 20
have been successful.
Autotransplantation could be recommended when:
I nterceptive measures are inappropriate or have failed.
The degree of malposition is too great to make ortho-
dontic alignment feasible.
Adequate space is available for the canine.
The prognosis is good for the tooth to be transplanted
and it can be removed atraumatically.
There is no evidence of ankylosis of the canine.
Sequelae of Canine Ectopia
I nternal or external root resorption of teeth adjacent to the
ectopic canine is the most common sequela. I t has been
estimated that 07 per cent of children in the 1013-year-old
age group have permanent incisors resorbed, as a result of
canine ectopia. Root resorption can be expected in about
125 per cent of the incisors adjacent to ectopic maxillary
canines (Ericson and Kurol, 1987a, b). Resorption of the
lateral incisor is more common than the central incisor.
Rarely the rst premolar is resorbed (Postletwaite, 1989).
A number of studies have found that females are more
likely to be affected (Sasakura et al., 1984; Rimes et al.,
1997). I f the canine has migrated to a position medial to the
mid-root of the lateral incisor, the resorption is more likely.
I n addition, if the angulation of the long axis of the canine
to the midline on an orthopantomogram exceeds 25
degrees the risk increases by 50 per cent (Ericson and
Kurol, 1988c). Lateral incisors are more commonly
resorbed palatally and at the mid root level than at the
cervical or apical regions (Ericson and Kurol, 1987b; Rimes
et al., 1997). There appears to be no association between
enlarged follicles surrounding the canine and the potential
for resorption. Cystic degeneration is uncommon and the
prevalence is not known. However, Ericson and Kurol
(1986a) found no evidence of cystic degeneration amongst
3000 school children. This is not surprising as it would be
expected that cystic degeneration would increase in
frequency in older age groups. However, even in older age
groups the frequency is thought to be low (Mourshed, 1964;
Brown et al., 1982). Lastly, late resorption of the unerupted
canine itself can occur (Kurol et al., 1997). Loss of vitality of
the incisors can occur and the poor aesthetics associated
with the primary canine may be a concern for the patient. I n
some cases the canine may erupt at a late stage under a
prosthesis. Surgical risks include damage to adjacent teeth,
re-exposure may sometimes be required and the potential
risks from general anaesthesia. Orthodontic treatment is
not without risks which include root resorption decal-
cication, periodontal problems, canine ankylosis, and
failure to complete treatment.
Acknowledgements
We acknowledge the helpful assistance of the Orthodontic
Audit Working Party (RCS Eng) in the preparation of this
paper. Many thanks to Dr D. Burden, Dr J. Husain, and Dr
R.T. Lee. for their collaboration. Thanks to Professor A.
Richardson for his helpful advice with the manuscript.
214 P. F. McSherry Scientic Section BJ O Vol 25 No. 3
References
Altonen, M. and Myllarniemi, S. (1976)
Results of surgical exposure of impacted cuspids and bicuspids in
relation to patients somatic and dental maturation,
I nternational J ournal of Oral Surgery, 5, 180186.
Andreasen, J . O. (1987)
Ectopic eruption of permanent canines eliciting resorption of
incisors: treatment by autotransplantation,
Tandbgbladet, 91, 487492.
Andreasen, J . O. (1992)
Atlas of Replantation and Transplantation of Teeth,
Mediglobe S A, Fribourg.
Becker, A., Smith, P. and Behar, R. (1981)
The incidence of anomalous maxillary incisors in relation to palatally
displaced cuspids,
Angle Orthodontist, 51, 2429.
Becker, A., Kokavi, D. and Zilbermann Y. (1983)
Periodontal status following alignment of palatally impacted canine
teeth,
American J ournal of Orthodontics, 84, 332336.
Becker, A., Zilbermann, Y. and Tsur, B. (1984)
Root length of lateral incisors adjacent to palatally displaced
maxillary cuspids,
Angle Orthodontist, 54, 218225.
Becker, A., Shpack, N. and Shteyer A. (1996)
Attachment bonding to impacted teeth at the time of surgical
exposure,
European J ournal of Orthodontics, 18, 457463
Bennett, J . and McLaughlin, R. (1997)
Orthodontic Management of the Dentition with the Preadjusted
Appliance,
I sis Medical Media, Oxford.
Berglund, L., Kurol, J . and Kvint, S. (1996)
Orthodontic pretreatment prior to autotransplantation of palatally
impacted maxillary canines: case reports on a new approach,
European J ournal of Orthodontics, 18, 449456.
Bishara, S. (1994)
I mpacted maxillary canines: a review,
American J ournal of Orthodontics and Dentofacial Orthopedics, 101,
159171.
Bishara, S., Kommer, D. D., Mc Neill, M. H., Montagano, L. H.,
Oesterle, L. H. and Youngqvist, H. W. (1976)
Management of impacted maxillary canines,
American J ournal of Orthodontics, 69, 371387.
Bjerklin, K., Gleerup, A. and Kurol, J . (1992)
Long term effects in children with ectopic eruption of the maxillary
rst permanent molars,
European J ournal of Orthodontics, 17, 293304.
Brenchley, Z. and Oliver, R. G. (1997)
Morphology of anterior teeth associated with displaced canines,
British J ournal of Orthodontics, 24, 4145.
Brin, I., Solomon, Y. and Zilbermann, Y. (1993)
Trauma as a possible etiologic factor in maxillary canine impaction,
American J ournal of Orthodontics and Dentofacial Orthopedics, 104,
132137.
Broadbent, B. H. (1941)
Ontogenic development of occlusion,
Angle Orthodontist, 11, 223241.
Brown, L. H., Berkman, S., Cohen, D., Kaplan, A. L. and
Rosenberg, M. (1982)
A radiological study of the frequency and distribution of impacted
teeth,
J ournal of the Dental Association of South Africa, 37, 627630
Coulter, J . and Richardson, A. (1997)
Normal eruption of the maxillary canine quantied in three
dimensions,
European J ournal of Orthodontics, 18, 449456.
Dachi, S. F. and Howell, F. V. (1961)
A survey of 3874 routine full mouth radiographs,
Oral Surgery, Oral Medicine, Oral Pathology, 14, 11651169.
Darendeliler, M. A. and Friedli, J . M. (1994)
Case report. Treatment of an impacted canine with magnets,
J ournal of Clinical Orthodontics, 28, 639643.
Ericson, S. and Kurol, J . (1986a)
Longitudinal study and analysis of clinical supervision of the
maxillary canine eruption,
Community Dentistry and Oral Epidemiology, 14, 172176.
Ericson, S. and Kurol, J . (1986b)
Radiographic assessment of maxillary canine eruption in children
with signs of eruption disturbance,
European J ournal of Orthodontics, 8, 133140.
Ericson, S. and Kurol, J . (1987a)
I ncisor resorption caused by maxillary cuspids. A radiographic
study,
Angle Orthodontist, 57, 332346.
Ericson, S. and Kurol, J . (1987b)
Radiographic examination of ectopically erupting maxillary canines,
American J ournal of Orthodontics, 91, 483492.
Ericson, S. and Kurol, J . (1988a)
Early treatment of palatally erupting maxillary canines by extraction
of primary canines,
European J ournal of Orthodontics, 10, 283295.
Ericson, S. and Kurol, J . (1988b)
CT diagnosis of ectopically erupting maxillary canines-a case report,
European J ournal of Orthodontics, 10, 115120.
Ericson, S. and Kurol, J . (1988c)
Resorption of maxillary lateral incisors caused by ectopic eruption of
the canines. A clinical and radiographic analysis of predisposing
factors,
American J ournal of Orthodontics and Dentofacial Orthopedics, 84,
503513.
Fox, N. A., Fletcher, G. A. and Horner, K. (1995)
Localizing maxillary canines using dental panoramic radiography,
British Dental J ournal, 179, 416420.
Galloway, I. and Stirrups, D. R. (1989)
The effect of age at diagnosis on complexity and outcome of
treatment of palatally ectopic canines,
British J ournal of Orthodontics, 16, 8792.
Grover, P. S. and Lorton, L. (1985)
The incidence of unerupted permanent teeth and related clinical
cases,
Oral Surgery, Oral Medicine, Oral Pathology, 59, 420429.
Harzer, W., Seifert, D. and Mahdi, Y. (1994)
The orthodontic classication of impacted canines with special
reference to the age at treatment, the angulation and the dynamic
occlusion,
Fortschritte der Kieferorthopdie/ J ournal of Orofacial Orthopedics,
55, 4753.
Hitchin, A. D. (1956)
The impacted maxillary canine,
British Dental J ournal, 100, 114.
Hultgren, B. W., Isaacson, R. J . and Frensch, P. A. (1994)
A case for specialty practice. Does practice make perfect...or
permanent?
Angle Orthodontist, 64, 231237.
Hunter, S. B. (1983)
Treatment of the unerupted maxillary canine. Part 2 Orthodontic
methods,
British Dental J ournal, 154, 324326.
Hurme, V. O. (1949)
Ranges of normalcy in the eruption of permanent teeth,
J ournal of Dentistry for Children, 16, 1115.
J acoby, H. (1979)
The Ballista Spring system for impacted teeth,
American J ournal of Orthodontics, 75, 143151.
BJ O August 1998 Scientic Section Ectopic Maxillary Canine 215
J acoby, H. (1983)
The etiology of maxillary canine impactions,
American J ournal of Orthodontics, 83, 125132.
Kettle, M. A. (1957)
Treatment of the unerupted maxillary canine,
Transactions of the British Society for the Study of Orthodontics,
pp. 7487.
Kohavi, D., Becker, A. and Zilbermann, Y. (1984)
Surgical exposure, orthodontic movement and nal tooth position as
factors in periodontal breakdown of treated palatally impacted
canines,
American J ournal of Orthodontics, 85, 7277.
Kokich, V. G. and Matthews, D. P. (1993)
Surgical and orthodontic management of impacted teeth,
Dental Clinics of North America, 37, 181204
Kristerson, L. (1985)
Autotransplantation of human premolars,
I nternational J ournal of Oral Surgery, 14, 200213.
Kuftinec, M. M., Stom, D. and Shapira, Y. (1995)
The impacted maxillary canine. I I . Clinical approaches and solutions,
J ournal of Dentistry for Children, 52, 325340.
Kurol, J ., Ericson, S. and Andreasen, J . O. (1997)
The impacted maxillary canine,
I n: Textbook and Color Atlas of Tooth I mpactions,
(ed. Andreason, J. O.)
Munksgaard, Copenhagen, pp. 124164
Machen, D. E. (1989)
Legal aspects of orthodontic practice: risk management concepts.
The impacted canine,
American J ournal of Orthodontics and Dentofacial Orthopedics, 96,
270271.
McSherry, P. F. (1996)
The assessment of and treatment options for the buried maxillary
canine,
Dental Update, 23, 710.
McSherry, P. F. and Richardson A. (1998)
Ectopic eruption of the maxillary canine quantied in three
dimensions on cephalometric radiographs between the ages of 5 and
15 years,
European J ournal of Orthodontics(in press).
Miller, B. H. (1963)
The inuence of congenitally missing teeth on the eruption of the
upper canine,
Transactions of the British Society for the Study of Orthodontics,
pp. 1724.
Moss, J . P. (1972)
The unerupted canine,
Dental Practitioner, 22, 241248.
Moss, J . P. (1974)
The indications for transplantation of the maxillary canine in the
light of 100 cases,
British J ournal of Oral Surgery, 12, 268274.
Mossey, P. A., Campbell, H. M. and Lufngham, J . K. (1994)
The palatal canine and the adjacent lateral incisor: a study of a West
of Scotland population,
British J ournal of Orthodontics, 21, 169174.
Mourshed, F. (1964)
A roentgenographic study of dentigerous cysts I . I ncidence in a
population sample,
Oral Surgery, Oral Medicine, Oral Pathology, 18, 4753.
Oliver, R. G, Mannion, J . E. and Robinson, J . M. (1989)
Morphology of the maxillary lateral incisor in cases of unilateral
impaction of the maxillary canine,
British J ournal of Orthodontics, 16, 916.
Orton, H. S., Garvey, M. T. and Pearson, M. H. (1995)
Extrusion of the ectopic maxillary canine using a lower removable
appliance,
American J ournal of Orthodontics and Dentofacial Orthopedics, 107,
349359.
Peck, S., Peck, L. and Kataja, M. (1994)
The palatally displaced canine as a dental anomaly of genetic origin,
Angle Orthodontist, 64, 249256.
Pirinen, S., Arte, S. and Apajalahti. S. (1996)
Palatal displacement of canine is genetic and related to congenital
absence of teeth,
J ournal of Dental Research, 75, 17421746.
Postletwaite, K. M. (1989)
Resorption of premolar roots by ectopic canines,
British Dental J ournal, 167, 397398.
Power, S. M. and Short, M. B. E. (1993)
An investigation into the response of palatally displaced canines to
the removal of deciduous canines and an assessment of factors
contributing to favourable eruption,
British J ournal of Orthodontics, 20, 215223.
Rayne, J . (1969)
The unerupted maxillary canine,
Dental Practitioner, 19, 194204.
Rimes, R. J ., Mitchell, C. N. T. and Willmot, D. R. (1997)
Maxillary incisor root resorption in relation to the ectopic canine: a
review of 26 patients,
European J ournal of Orthodontics, 19, 7984.
Roberts-Harry, D and Harradine, N. (1995)
A sectional approach to the alignment of ectopic maxillary canines,
British J ournal of Orthodontics, 22, 6770.
Sandler, P. J ., Meghji, S., Murray, A. M., Springate, S. D., Sandy, J .
R., Crow, V. and Reed, R. T. (1989)
Magnets and orthodontics,
British J ournal of Orthodontics, 16, 243249.
Sasakura, H., Yoshida, T., Murayama, S., Hanada, K. and
Nakajima,T. (1984)
Root resorption of the upper permanent incisor caused by the
impacted canine,
I nternational J ournal of Oral Surgery, 13, 299306.
Schatz, J . P., Byloff, F., Bernhard., J . P. and J oho, J . P. (1992)
Severely impacted canines: autotransplantation as an alternative,
I nternational J ournal of Adult Orthodontics and Orthognathic
Surgery, 7, 4552
Schmuth, G. P., Freisfeil, M., Koster, O. and Schuller, H. (1992)
The application of computerized tomography (CT) in cases of
impacted maxillary canines,
European J ournal of Orthodontics, 14, 296301.
Semb, G. and Schwartz, O. (1997)
The impacted tooth in patients with alveolar clefts,
I n: Textbook and Color Atlas of Tooth I mpactions,
(ed. Andreason, J. O.)
Munksgaard, Copenhagen, pp. 331348
Shah, R. M., Boyd, M. A. and Vakil, T. F. (1978)
Studies of permanent tooth anomalies in 7886 Canadian individuals,
J ournal of the Canadian Dental Association, 44, 262264.
Southall, P. and Gravely, J . (1987)
Radiographic localization of unerupted teeth in the anterior part of
the maxilla: a survey of the methods currently employed,
British J ournal of Orthodontics, 14, 235242.
Thilander, B. and J acobsson, S. O. (1968)
Local factors in impaction of maxillary canines,
Acta Odontologica Scandinavica, 26,145168.
Usiskin, L. A. (1991)
Management of the palatal ectopic and unerupted maxillary
canine,
British J ournal of Orthodontics, 18, 339346.
Vanarsdall, R. L. and Corn, H. (1977)
Soft tissue management of labially positioned unerupted teeth,
American J ournal of Orthodontics, 72, 5377.
Vermette, M. E., Kokich, V. G. and Kennedy, D. B. (1995)
Uncovering labially impacted teeth: apically positioned ap and
closed eruption techniques,
Angle Orthodontist, 65, 2332.
216 P. F. McSherry Scientic Section BJ O Vol 25 No. 3
Woloshyn, H., Artun, J ., Kennedy, D. B. and J oondeph, D. R. (1994)
Pulpal and periodontal reactions to orthodontic alignment of
palatally impacted canines,
Angle Orthodontist, 64, 257264.
Wong Lee, T. K. and Wong, F. C. (1985)
Maintaining an ideal tooth gingiva relationship when exposing and
aligning an impacted tooth,
British J ournal of Orthodontics, 12, 189192.
Zachrisson, B. U. and Thilander, B. (1985)
I ntroduction to Orthodontics, 5th edn,
Tandlkafrlaget Stockholm, p. 176.
Zilberman, Y., Cohen, B. and Becker, A. (1990)
Familial trends in palatal canines, anomalous lateral incisors, and
related phenomena,
European J ournal of Orthodontics, 12, 135139.