220

I
mpacted teeth, those that are prevented completely or
partially from eruption, are often identified as ortho-
dontic problems. The maxillary canine is the second
most frequently impacted tooth observed in the human
permanent dentition, after the third molars.
1,2
According to Dewel,
3
no tooth is more interesting
from a development point of view than the maxillary
canine. The canine develops in the deepest area of the
maxilla, follows the longest path of eruption, and
erupts into the occlusal plane only after the adjacent
teeth do. In a 3-dimensional study of the eruption pat-
tern of the canine, Coulter and Richardson
4
found that
the maxillary canine traveled 22 mm during its course
of eruption. It is not surprising, then, that ectopic erup-
tion or impaction of the maxillary canine is a fre-
quently encountered tooth malposition.
In 70% to 85% of cases of maxillary canine
impaction in populations of European origin, the
canine is displaced palatal to the dental arch.
5-8
The
reported prevalence rates for palatally displaced
canines (PDC) range from 1% to 3% in European pop-
ulation samples.
5-8
The 2 other impaction phenotypes
for the maxillary caninewith the tooth displaced
labial to the dental arch or found over the dental
ridgeare usually very different phenomena than
palatal displacement and subsequent impaction of the
canine. In fact, labial displacement of maxillary
canines is understood as a simple product of inadequate
dental arch space.
7,9
Thilander and Jakobsson
10
found
that dental crowding usually displaced the canine in a
labial direction, which delayed eruption, but rarely
caused a lasting impaction. Jacoby
7
reported that 83%
of arches with labial displacement of maxillary canines
displayed dental arch space deficiency. Further,
Jacoby
7
was among the first to suggest anecdotally that
dental crowding and arch length deficiency were not
associated features of the PDC malposition. Thus,
palatal and labial canine malpositions appear to be very
different phenomena,
8,9,11,12
and assumptions that they
share a common cause are incorrect.
We are beginning to understand why the maxillary
canine displaces frequently in such a peculiar palatal
fashion. Recent studies have pointed to a biologic
genetic origin for the PDC phenomenon, by recogniz-
ing its familial occurrence and by associating its occur-
rence with the increased presence of other dental
anomalies, such as tooth agenesis and tooth size reduc-
tion.
11,13,16
Added insight into the underlying mecha-
nism comes now from McSherry and Richardson,
17
who describe a specially programmed eruptive path-
way for the PDC. Studying serial frontal and lateral
cephalograms of children from ages 5 to 15 years, they
found that the PDC never moves labially in its entire
From the Harvard School of Dental Medicine, Department of Growth and
Development, Program in Orthodontics and Dentofacial Orthopedics.
a
Research Fellow in Orthodontics, Department of Growth and Development,
Harvard School of Dental Medicine, Boston, Mass.
b
Associate Clinical Professor, Department of Growth and Development (Ortho-
dontics), Harvard School of Dental Medicine, Boston, Mass.
Reprint requests to: Dr Blaine J. Langberg, Program in Orthodontics, Depart-
ment of Growth and Development, Harvard School of Dental Medicine, 188
Longwood Ave, Boston, MA 02115; e-mail, blaine_langberg@student.hms.
harvard.edu.
Submitted, November 1999; Revised and accepted, December 1999.
Copyright 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/104819
doi.10.1067/mod.2000.104819
SHORT COMMUNICATION
Adequacy of maxillary dental arch width in patients with
palatally displaced canines
Blaine J. Langberg, DMD,
a
and Sheldon Peck, DDS, MScD
b
Boston, Mass
This study investigates maxillary dental arch width in subjects with palatally displaced canines. Pretreatment
dental casts of orthodontic patients with one or both maxillary canines palatally displaced (n = 31; male, 10;
female, 21) were collected. This sample was matched according to sex and age with pretreatment dental casts
from unaffected orthodontic patients. Arch widths were recorded between the maxillary first premolars and
between the maxillary first molars. Interpremolar arch width and intermolar arch width comparisons between
the sample with palatally displaced canines and the reference sample showed no statistically significant dif-
ferences in their means, thus indicating that there was no statistically significant difference in the anterior and
posterior arch width between the affected subjects and the control subjects. Thus, affected patients exhibit
adequacy of maxillary dental arch width. This evidence refutes earlier conclusions that deficiency in maxillary
transverse arch width is an associated contributing factor in the genesis of the anomaly of palatally displaced
canines. Clinically, adequacy of dental arch width helps explain the nonextraction diagnostic appearance of
most of these patients when they present for treatment. (Am J Orthod Dentofacial Orthop 2000;118:220-3)
C
E
American Journal of Orthodontics and Dentofacial Orthopedics Langberg and Peck 221
Volume 118, Number 2
1. IP1, the intermaxillary arch width of the maxillary
first premolars, measured by placing the caliper
tips into the deepest portion of the central fossae
at its junction with the most lingual aspect of the
facial cusp, which approximates the centroid of
the tooth as described by Moyers et al.
19
This
measurement represents the anterior arch width.
2. IM1, the intermaxillary arch width measurements
of the first molar, taken with the caliper tips placed
into the deepest portion of the central fossae at its
junction with the most lingual aspect of the
mesiobuccal cusp. Intermolar arch width repre-
sents posterior arch width.
Measurement data from the patients with PDC were
compared with data from the control sample population.
The Student t test was used to test differences between
the mean values of the measurements IP1 and IM1
found for the 31 PDC subjects and for the 31 age- and
gender-matched control sample. The null hypothesis to
be tested was that the maxillary interpremolar widths
and intermolar widths in PDC patients do not differ from
those found in a typical orthodontic population.
Intraexaminer reliability was assessed using a double
determination method. The dental casts were measured
twice by the same operator, with a 1-week separation
between each set of measurements. Calculations were
made for the interpremolar and intermolar measure-
ments, computing the mean absolute difference between
determinations, the mean signed difference, the standard
deviation of the signed difference, and the error of the
method for each of the variables mentioned. Table I
shows the results of this error analysis, which were rea-
sonably consistent with expectations. Thus, these several
approaches to quantify the error of the method point to
good measurement reliability and reproducible methods.
RESULTS
Maxillary interpremolar arch width and intermolar
arch width comparisons between the PDC sample and
the reference sample showed no statistically significant
differences in their means (Table II). Therefore, there is
no statistically significant difference in the anterior and
posterior arch width between the PDC subjects and the
control subjects.
development. Quite remarkably, between the ages of 10
and 12 years, the PDC does not undergo the labial
movement observed of a normally erupting canine, but,
in fact, continues to descend on a palatal pathway
throughout its development.
On a different track, McConnell et al
18
have impli-
cated deficiency in maxillary width as a local mechan-
ical cause of the PDC malocclusion. They studied a
sample of orthodontic patients diagnosed with maxil-
lary canine impactions. Over 70% of their subjects had
the PDC anomaly. They concluded that patients with
canine impactions have transverse maxillary defi-
ciencyin the anterior portion of the dental arch.
Because no other publication to date has examined this
purported relationship, the present study was devised to
investigate whether maxillary arch width deficiency is
associated with the occurrence of PDC.
MATERIAL AND METHODS
Pretreatment dental casts of 31 nonsyndromic ortho-
dontic patients (male, 10; female, 21) with palatal dis-
placement of one or both canines were evaluated. This
PDC sample was selected according to a clear-cut diag-
nosis of palatal ectopic displacement of the anomalous
canines, based on panoral, periapical, and occlusal
radiographs, and clinical history. The 31 PDC subjects
were self-identified as white from northeastern United
States. The range of ages for the PDC patient sample
was from 11 to 17 years with a mean of 13.6 years and
a median of 14.0 years. The control reference sample
consisted of pretreatment dental casts of 31 non-PDC
orthodontic patients matched according to age
(rounded to the whole year) and to sex with the PDC
subjects. Information on racial self-identity of the con-
trol subjects was not available.
Pretreatment measurements were recorded for the
PDC subjects (n = 31) and for the control sample (n =
31). Measurements to the nearest 0.01 mm were taken
from pretreatment maxillary dental casts using an
odontometric dial caliper, with the cast placed on a flat
surface and the caliper tips oriented perpendicular to
the occlusal plane. Reference points for transverse arch
width measurements were selected on the basis of easy
reproducibility. The following measurements were
recorded (in millimeters):
Table I. Error analysis with 61 double-determinations
Mean absolute Mean signed SD of the signed Error of th
Measurement difference difference difference method
Interpremolar width (mm) 0.17 0.068 0.23 0.029
Intermolar width (mm) 0.34 0.088 0.59 0.045
222 Langberg and Peck American Journal of Orthodontics and Dentofacial Orthopedics
August 2000
Our study is the first to question the results of
McConnell et al
18
and to present evidence that sub-
jects with palatal canine impactions actually do not
demonstrate transverse maxillary deficiency in either
the anterior or posterior portion of the dental arch.
Therefore, we confidently conclude that maxillary
arch width is not a primary contributory factor in the
genesis of the PDC anomaly. These results are easy to
reconcile with the strong evidence pointing to pro-
grammed genetic mechanisms underlying the occur-
rence of the PDC anomaly.
Because this study measured jaw width as repre-
sented by intra-arch dental measurements, there may
still be a question of relationship between the true
skeletal transverse maxillary dimensions and the PDC
phenomenon. It is reasonable to suspect that evidence
of adequacy in maxillary intermolar and interpremolar
widths from our study would indicate similar adequacy
in the size and capacity of the maxillary basal bone in
patients with clear-cut PDC malpositions. Future stud-
ies with anteroposterior cephalometric projections of
PDC patients may be helpful in further testing and ana-
lyzing of skeletal maxillary widths. The Ricketts J-
point measurement has been proposed to provide an
accurate, anatomic indicator of transverse skeletal
dysplasia
23
; however, scientific evidence is still lack-
ing to validate its usefulness in this regard.
This study does not support the conclusion of
McConnell et al
18
that maxillary orthopedic expansion
would be an interceptive modality in treating children
with PDC. Furthermore, this study supports the
nonextraction diagnostic appearance of PDC
patients. Because PDC is not associated with a pattern
of constricted maxillary arch form and because the
teeth of PDC patients tend to be smaller than average,
16
permanent teeth usually do not need to be extracted in
order to find space for the palatal canine.
We thank 3 faculty members at the Harvard School
of Dental Medicine: Dr Catherine Hayes for her con-
DISCUSSION
The present study investigates associations between
transverse maxillary arch width and the PDC maloc-
clusion. Arch width measurements of PDC subjects
compared with a control group of age- and gender-
matched orthodontic patients indicate that there is no
statistically significant difference in the anterior and
posterior maxillary arch width between PDC subjects
and a sample of control subjects.
These results contradict those from a study by
McConnell et al,
18
who reported that subjects with
maxillary canine impactions had transverse maxil-
lary deficiency exhibited in the anterior portion of the
dental arch. The mean intercanine width for their
experimental group (those with impacted canine) was
26.91 mm (SD, 3.83) and the mean intercanine width
for their control group was 31.24 mm (SD, 1.96). The
study determined that the mean intercanine width for
the experimental group was two SDs below that of the
control group, which was determined to be profoundly
different.
18
However, the examiners did not identify the
precise position of the unerupted maxillary canines in
their subjects, and labial impaction subjects were not
differentiated from PDC subjects. Their sample was a
mix of approximately 71% PDC cases and 29% with
labial displacement of the maxillary canine. Additional
uncertainty was introduced by the method they used to
secure their anterior arch width measurements. The
investigators attempted to predetermine visually the
site where the unerupted impacted canine would nor-
mally erupt on the dentoalveolar ridge to establish their
measurement points, an unreliable estimate contraindi-
cated for a quantitative study.
Before the McConnell study,
18
no data documented
diminished arch width or transverse maxillary defi-
ciency as a possible etiologic factor for impacted max-
illary canines. In fact, clinical observations
8
have asso-
ciated adequate maxillary size and form with the PDC
anomaly because the typical orthodontic treatment plan
for this condition involves neither palatal expansion
techniques nor permanent tooth extractions.
If transverse maxillary deficiency were a significant
factor in the genesis of the PDC impaction anomaly,
Asian populations, which characteristically exhibit
greater frequency of maxillary underdevelopment, den-
tal crowding, and extraction orthodontic treatment than
European groups do, would be expected also to have a
greater prevalence of the PDC anomaly. Evidence
shows this is not the case.
20-22
Palatal displacement of
the canine is predominantly a European trait, occurring
5 times more frequently in those of European origin
than in those of Asian origin.
8
Table II. Comparisons of interpremolar transverse arch
width and intermolar transverse arch width in the PDC
sample vs control-reference sample (in millimeters)
Variable n Mean SD t test P
Interpremolar width
PDC cases 31 33.98 2.30 0.138 .891
Controls 31 33.90 2.41 NS
Intermolar width
PDC cases 31 43.36 2.17 1.113 .270
Controls 31 44.04 2.63 NS
American Journal of Orthodontics and Dentofacial Orthopedics Langberg and Peck 223
Volume 118, Number 2
tributed expertise in data management, Dr Leslie Will
for her endorsement of this project in partial fulfillment
for the first authors DMD degree, and Dr Samer
Zawaideh for his constructive comments.
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