ORIGINAL ARTICLE

Three-dimensional localization of maxillary

canines with cone-beam computed tomography
Leah Walker,a Reyes Enciso,b and James Mahc
Los Angeles, Calif
Introduction: Precise 3-dimensional (3D) localization of impacted canines is central to their clinical
management. Recently introduced dental 3D volumetric imaging systems make precise localization possible.
The purpose of this study was to describe the spatial relationship of impacted canines by using images
obtained with the NewTom QR-DVT 9000 (QR Srl, Verona, Italy). Methods: Unilaterally and bilaterally
impacted canines (n 27) from 19 consecutive patients (15 female, 4 male) were evaluated on images taken
with the NewTom QR-DVT 9000. The spatial relationships of the impacted canines relative to adjacent
structures and incisor resorption were assessed with 3D visualization software. Results: Most (92.6%) of the
27 impactions were palatal. Incisor resorption adjacent to the impacted canine was present in 66.7% of the
lateral incisors and 11.1% of the central incisors. Follicle size did not play a major role in influencing impacted
canine position. The alveolus was narrower at the impacted canine side compared with the erupted canine
side; however, the width of the alveolus on the impacted canine side is independent of the deciduous
canines. A correlation was found between the proximity of the impacted canine to the incisors and their
resorption. There was no common location where eruption was arrested, and great variation in the inclination
of the impacted canine was found. Conclusions: 3D volumetric imaging of impacted canines can show the
following: presence or absence of the canine, size of the follicle, inclination of the long axis of the tooth,
relative buccal and palatal positions, amount of the bone covering the tooth, 3D proximity and resorption of
roots of adjacent teeth, condition of adjacent teeth, local anatomic considerations, and overall stage of dental
development. In short, 3D imaging is clearly advantageous in the management of impacted canines. (Am J
Orthod Dentofacial Orthop 2005;128:418-23)

mpacted canines are relatively common in orthodontic practice. After the third molar, the maxillary
canine is the most frequently impacted tooth.1,2
The mandibular canine is much less of a concern
because it is 10 times less frequently impacted.2-4 The
prevalence of impacted maxillary canines is reported to
be 2%,2 0.9% to 2%,4 1% to 2%,5 1.5% to 2%,6 and 1%
to 3%.7 The maxillary impacted canine is more often
located palatally (85%) than labially (15%).2-4 Impacted canines can also lead to the resorption of
neighboring permanent teeth, particularly the lateral
incisors. Various degrees of resorption on the permanent incisors have been reported, and, in 1 study,
resorption was associated with approximately 48% of
impacted maxillary canines.8 Additionally, resorption
From the Division of Craniofacial Sciences and Therapy, School of Dentistry,
University of Southern California, Los Angeles.
a
Visiting researcher.
b
Clinical assistant professor.
c
Associate clinical professor.
Reprint requests to: James Mah, School of Dentistry, University of Southern
California, 925 West 34th St, Room 312, Los Angeles, CA 90089-0641; e-mail,
jamesmah@usc.edu.
Submitted, October 2003; revised and accepted, April 2004.
0889-5406/$30.00
Copyright 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.04.033

418

can be difficult to diagnose with conventional methods,

especially if the canine is located in a direct palatal or
buccal position relative to the incisor roots.9
The orthodontic-surgical management of impacted
canines requires accurate diagnosis and precise location
of the impacted canine and the surrounding structures.10 It is important to define the exact position
relative to neighboring structures and the inclination of
the longitudinal axis of the impacted tooth. Diagnosis
and treatment planning can be difficult with conventional radiographic methods, because of superimposition of structures on the film; this often makes it
difficult to distinguish details.2 Distortion and projection effects are also encountered with conventional
radiographs. Recently, computed tomographic scanning (CT) has been used, because it can provide more
reliable information than conventional methods.9,11 CT
provides excellent tissue contrast, eliminating blurring
and overlapping of adjacent teeth.2 Despite its advantages, until now, the use of CT for location of impacted
teeth and assessment of resorption has been restricted
because of issues related to cost, risk/benefit, access,
and expertise in reading the CT.12
A newly developed dental volumetric imaging device, the NewTom QR-DVT 9000 (QR Srl, Verona,

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

Italy), uses cone-beam radiation to gather similar information in the working range of dental radiography. The
effective absorbed radiation dose for a maxillomandibular imaging session with the NewTom QR-DVT
9000 is 50.2 Sv13; traditional medical CT results in an
effective absorbed radiation dose from 124.9 to 528.4
Sv for a mandibular examination and 17.6 to 656.9
Sv for a maxillary examination, depending on the
volume of the arch imaged and the operational settings
of the CT.13 The effective dose with a panoramic
examination is 2.9 to 9.6 Sv14 and that for a fullmouth series is 33 to 84 Sv14 or 14 to 100 SV,15
depending on variables such as film speed, technician,
kVp, and collimation.
The aim of this study was to quantify the spatial
relationship of impacted maxillary canines by using
3-dimensional (3D) volumetric imaging. The following
factors were analyzed: proximity to adjacent structures,
resorption of incisors, alveolar width, and follicle size.
Results for 19 consecutive subjects referred for imaging
with a diagnosis of impacted canines are presented
here.
MATERIAL AND METHODS

Cone beam CT images were collected from 19

consecutive patients (15 female, 4 male) who were
referred for localization of either unilateral or bilateral
impacted or ectopically erupting canines (images courtesy of Dr David Hatcher). These clinical situations are
considered here as a single group when describing the
localization; a diagnosis was not made because complete patient data were not available. A total of 27
impacted or ectopically erupted maxillary canines were
studied, including 16 bilateral impactions, 5 left unilateral impactions, and 6 right unilateral impactions. The
patients ages ranged from 8 to 20 years (average, 13.3;
SD, 2.98). The age of 1 patient with a unilateral
impaction was unavailable.
In 48.1% of the cases, the deciduous canine was
still present. Of these, 33.3% were overretained. Overretention was determined by the patients chronological
age and the average age in which the deciduous canine
exfoliates (11 years 9 months for maxillary canines16).
In the sample, 61.1% of the patients had adult
dentitions, and 38.9% were still in the mixed-dentition
stage (not including the patient whose age was missing). Of the mixed-dentition patients, the impacted
canine was evaluated before eruption of either the first
or the second premolar.
The NewTom QR-DVT 9000 is a dental maxillofacial volumetric imaging system with a reconstruction
volume of 110 150 mm and an imaging time of about

Walker, Enciso, and Mah 419

75 seconds. The device acquires 360 images at 1

intervals, with a resolution of 512 512 pixels and 8
bits per pixel (256 greyscale). The reconstruction matrix voxel is 0.25 0.25 0.3 mm.
Software from the manufacturer allows for secondary reconstructions to be produced that show many
viewpoints of the structures of interest. These secondary reconstructions include transaxial, panoramic, and
3D views. Measurements were made on these views
(distances and angles).
Imaging data were analyzed with software from the
manufacturer. This study focused on the following:
1. Type of impaction.
2. Resorption of incisors.
3. Proximity of the impacted canine to the lateral and
central incisors. This was measured as the shortest
distance between the impacted canine and the
incisor. Contact was defined as proximity of less
than 0.5 mm.
4. Follicle size measured at the widest area from the
crown to the periphery of the follicle (Fig 1). If the
dimension from the crown to the periphery of the
follicle was less than 2 mm, it was considered to be
within normal limits, and if it was greater than 2
mm, it was considered to be an enlarged follicle.
5. Existence of deciduous canines.
6. Alveolar width in the area of the canine (both
impacted and normally erupted). This was measured at the level of the cervical margin of the
adjacent teeth of both left and right sides.
7. Location. This was determined from 3 views: coronal or frontal (Fig 2), sagittal (Fig 3), and axial or
horizontal (Fig 4). Distances and angles were measured with the NewTom software on these views.
For assessment of location, reference lines were
created that consisted of a horizontal occlusal plane line
and a vertical line bisecting the midline of the jaws. All
distances were measured perpendicularly from the reference lines to the cusp tip of the tooth. The angles
measured were the angles formed by the line bisecting
the long axis of the tooth and the reference line. From
the coronal view, the following measurements were
taken: distance from cusp tip of the impacted canine to
the occlusal plane, distance from cusp tip of the
impacted canine to the midline, angle of the impacted
canine to the occlusal plane, and angle of the impacted
canine to the midline. From the sagittal view, the
following measurements were taken: distance from the
cusp tip of the impacted canine to the occlusal plane,
distance from the cusp tip of the impacted canine to the
frontal plane, angle of the impacted canine to the
occlusal plane, angle of the lateral incisor to the

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American Journal of Orthodontics and Dentofacial Orthopedics

October 2005

Fig 1. Follicles were measured in millimeters from

crown to periphery of follicle (axial view).

Fig 3. Angle of impacted canine to occlusal plane

(19.5) and distance of cusp tip from occlusal plane
(24.2 mm).

than 1 or 2 mm (depending on the factor being

measured) were measured to the nearest half millimeter. All measurements were made twice, and the mean
was reported.
RESULTS

Fig 2. Distances of cusp tip of impacted canine to

midline and occlusal plane. Tooth was visible only from
incisal view.

occlusal plane, and angle of the central incisor to the

occlusal plane. From the axial view, the following
measurements were taken: distance from the cusp tip of
the impacted canine to the midline and angle of the
impacted canine to the midline.
In this study, angles greater than 5 were reported
(angles less than 5 were too indistinct to allow for
more accurate measurement), and distances greater

Most of the patients with impacted canines in this

study (78.9%) were female. There was no significant
difference between left and right impactions. Most
of the maxillary impactions were located palatally
(92.6%), and only 7.4% were located buccally. One
buccally impacted canine was between the premolars,
with resorption of the first premolar.
Of the 27 cases of impacted maxillary canines, 21
incisors were resorbed, including 18 lateral incisors
(66.7% of 27 cases) and 3 central incisors (11.1% of 27
cases) (Table I). All central incisor resorption cases
also had lateral resorption. In 1 subject, both lateral
incisors were missing. In 1 impaction case, the resorption was on the first premolar. In all bilateral cases,
which had lateral resorption, both laterals were
resorbed. In the only bilateral case in which the central
incisor was resorbed, the resorption was unilateral.
The impacted canine in 63.0% of the 27 cases was
in contact (distance less than 0.5 mm) with the lateral
incisor, and, in 18.5% of the 27 cases, the impacted
canine was in contact with the central incisor (Table II).
The average distances of the impacted canine to the

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American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

Table I.

Incisor resorption associated with 27 impacted

canines
Incisors

Resorption

No resorption*

Lateral
Central

18/27 (66.7%)
3/27 (11.1%)

9/27 (33.3%)
24/27 (88.9%)

*Includes 2 missing lateral cases.

Table II.

Proximity between 27 impacted canines and

adjacent incisors
Incisors

Contact

No contact*

Lateral
Central

17/27 (63.0%)
5/27 (18.5%)

10/27 (37.0%)
22/27 (81.5%)

*Includes 2 missing lateral cases.

average widths of the alveolus were 10.6 1.04 mm at

the erupted canine cervical margin and 8.0 2.67 mm
on the affected side (Table III).
The distances measured from the impacted canine
to the midline varied to some extent in the coronal and
axial views. Averages for the distance of the cusp tip of
the impacted canine to the midline were 10.8 4.17
mm and 10.6 3.96 mm in the axial and coronal
views, respectively. The distance from the cusp tip of
the impacted canine to the frontal plane averaged 7.9
3.18 mm in the sagittal view. The greatest variation was
found from the cusp tip of the impacted canine to the
occlusal plane in the coronal and sagittal views.

Fig 4. A, Angle of impacted canine to midline (4.6) in

axial view (does not accurately depict tip of cusp). B,
Distance from cusp tip to midline (16.8 mm).

DISCUSSION

lateral incisor and central incisor were 1.4 2.15 mm

(Fig 5) and 3.5 2.90 mm (Fig 6), respectively.
By using the measurements shown in Figure 1,
approximately half of the impacted canine follicles
examined were within normal limits (53.8%). The
remaining cases (46.2%) were considered enlarged
( 2 mm). Follicle size varied from less than 2 to 8.7
mm, with an average of 3.6 mm. In one case, the
follicle was not detected.
Of the 27 impacted cases evaluated, 13 had deciduous canines (48.1%) and 14 (51.9%) did not.
From an axial view, the width of the alveolus at the
erupted canine cervical margin was measured and
compared with the width of the alveolus of the affected
side at the level of the cervical margin of the adjacent
teeth for the unilateral impacted canine cases. In all
cases but 1, there was a clinical decrease in the width of
the alveolus at the affected side compared with the
width of the alveolus of the erupted canine. The

Incisor resorption adjacent to the impacted canine

was present in 66.7% of the laterals and 11.1% of the
centrals (Table I). The percentage of resorbed centrals
is comparable with previous reports using CT images in
which 9% of the centrals were resorbed.8 In our study,
only 1 case involved the resorption of the first premolar, suggesting that resorption of the first premolar is
unusual.
This study supports previous claims that resorption
on maxillary incisors after ectopic eruption of the
maxillary canines is a relatively common phenomenon
and must be considered in all patients with seriously
diverging eruption of the maxillary canines.8 There was
a correlation between the proximity of the impacted
canine to the lateral incisor and the central incisor, and
the resorption of the incisors caused by the impacted
canine. The impacted canine was in contact (shortest
distance less than 0.5 mm) with the lateral incisor in
63.0% of the cases and with the central incisor in 18.5%
of the cases (Table II). This information is supported by

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American Journal of Orthodontics and Dentofacial Orthopedics

October 2005

Fig 5. Proximity of impacted canine to lateral incisor.

Fig 6. Proximity of impacted canine to central incisor.

the results of a previous study in which 93% of the

impacted canines were in contact with roots of the
adjacent lateral incisor and 19% with the central incisor.8 Resorption was present when the impacted canine
was within 0.5 mm of the lateral incisor, and, in 1
exceptional case, resorption occurred with proximity of
2.3 mm (Fig 5). Two of the 3 resorbed central incisors
had the impacted canine within 0.5 mm of the central
incisor (Fig 6). However, in 3 other cases, proximity of
the impacted canine to the central incisor was less than
0.5 mm, with no resorption. The exceptions for both the
central and lateral incisors were in the same patient, and
an enlarged follicle surrounded the impacted canine.
This correlation supports previous claims that there
must be close contact between the canine and the lateral
incisor rather than mediation of resorption by swelling
of the dental follicle.4
The widths of the dental follicle of the impacted
canines varied greatly. There was no correlation between follicle size and impaction of the canine. This

result suggests that follicle size does not play a major

role in influencing impacted canine position.
There was no significant correlation between presence of deciduous canine and width of the alveolus on
the impacted canine side. This suggests that alveolus
width is independent of the deciduous canines.
Measurements made on different views showed that
the distance from the cusp tip of the impacted canine to
the midline of the jaws is relatively constant, whereas
the distance from the cusp tip of the impacted canine to
the occlusal plane varies widely. This indicates that
impactions vary greatly, and there is no common mode
of impaction. There is considerable variation to the
inclination of the impacted canine; some are horizontally impacted, and others are vertically impacted with
variations in between.
The prevalence of maxillary canine impactions
seems to vary within a range of 0.9% to 3.0%,2,4-7 with
a higher prevalence in females.17-20 In our study sample, we had more females than males. One can only

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American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

Table III.

Width of alveolus measured (in mm) at

erupted canine cervical margin and on affected side at
level of cervical margin of adjacent teeth. Missing
alveolar measurements correspond to bilateral impactions
Case #

At erupted canine
cervical margin

On affected side

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

10.50
10.75
9.75

10.0
9.85

13.25

10.20
10.30

11.65

10.20

9.85

3.55
6.45
7.95

6.15
8.10

14.20

8.60
9.65

9.45

Average
SD
Variance

10.6
1.04
1.08

8.0
2.67
7.13

6.80

7.20

speculate on the possible reasons for this finding. It

could be related to differences in overall craniofacial
growth and development between the sexes or genetics,
or simply because more girls and women seek orthodontic treatment. This study also showed that palatal
maxillary impactions (92.6%) are more common than
buccal impactions (7.4%); this agrees with previous
reports.2-4,20
CONCLUSIONS

Our findings demonstrate that the 3D volumetric

imaging provides invaluable information about impacted canines to better understand and treat these cases
surgically and orthodontically.

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