Original Article

Management of Ectopic Maxillary Canines

Variations Among Orthodontists

Krister Bjerklina; Lars Bondemarkb

ABSTRACT Objective: To document and analyze factors involved in decision-making by orthodontists in managing disturbances of eruption of maxillary canines. Materials and Methods: The participants comprised orthodontic specialists and active members of the Swedish Orthodontic Society. Those selected for the study sample were under 65 years of age or younger and had been treating orthodontic patients for at least 1 year as a specialist. Three typical cases were presented for treatment proposals. The case notes, including radiographs and specic background data, were sent to the 182 selected orthodontists. The orthodontists were also requested to complete a questionnaire about practice prole, comprising eight questions. Results: The response rate was 86.3%; yielding 157 participants (mean age 53.8 years, SD 8.12). Analysis disclosed no differences between responders and nonresponders regarding age, gender, and years of specialist practice. For treatment plans based on panoramic radiographs, intraoral radiographs, and status and anamnesis, there was general consensus. However, when supplementary information from computer tomography (CT) was provided, disclosing root resorption halfway to the pulp or more on the lateral incisor, the orthodontists treatment proposals varied. Gender, age, and practice prole of the orthodontists had little association with the decisionmaking. Conclusions: Supplementary CT information led to variations in decision-making with respect to treatment of eruption disturbances of maxillary canines. This lack of consensus among specialist orthodontists can have negative implications for patients. KEY WORDS: Orthodontic treatment; Decision-making; Eruption disturbances; Maxillary canines

INTRODUCTION From a clinicians perspective the quality of treatment outcomes is determined by the quality of the judgments and decisions that govern how we act, and the skill with which those actions are carried out.1 However, the profession has done little to evaluate
Associate Professor, Department of Orthodontics, Institute for Postgraduate Dental Education, Jonkoping, Sweden. b Professor, Department of Orthodontics, Malmo University, Malmo, Sweden. Corresponding author: Dr Krister Bjerklin, Department of Orthodontics, Institute for Postgraduate Dental Education, Hermansvagen 5, SE 554 53 Jonkoping, Sweden (e-mail: krister.bjerklin@lj.se)
a

Accepted: September 2007. Submitted: July 2007. 2008 by The EH Angle Education and Research Foundation, Inc.
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judgmental and decision-making processes. In the orthodontic literature, the few reports on clinicians decision-making concern predominantly the consistency of orthodontic extraction decisions.2,3 These studies disclosed poor interclinician agreement on whether or not to extract,3 the orthodontists applying different criteria in terms of the extraction decision. This lack of consensus can have negative implications for patients.2 Further issues on which a lack of consensus has been highlighted include the best time to initiate treatment and factors that preclude early treatment4 and the orthodontists approach to referral of post-orthodontic patients for lower third molar treatment.5 After the third molars, the maxillary permanent canines are the teeth most frequently impacted. The reported prevalence is 1.0%2.2%.611 Early detection of ectopically positioned maxillary canines is important as it allows the canine to be monitored radiographically:
DOI: 10.2319/070307-306.1

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853 response was received within an additional 3 weeks, a nal reminder was issued. No further attempt was made to contact the nonresponders. A code list was made of the selected orthodontists and the study was registered according to the Swedish Law of Personal Integrity (PUL). Cases and Questionnaire Three cases with radiographs (Figures 1 through 3), supplemented by specic background data, were presented for assessment by the orthodontists. The participants were also requested to complete a questionnaire comprising eight questions. Case 1 A 12-year-old boy with Class I occlusion, normal maxillomandibular skeletal relationship. Normal soft tissue prole. Maxillary canines in ectopic positions, not clinically palpable. Severe space deciency in the maxilla. The mandibular right rst premolar has already been extracted. On the basis of the above information and their assessment of the radiographs, the orthodontists were required to decide which tooth/teeth should be extracted. Further information was then provided, namely computed tomography examination has disclosed the left lateral incisor to have root resorption half-way to the pulp in the midsection of the root. In light of this new information, the orthodontists were required to review their recommendation as to which maxillary tooth/ teeth should be extracted. Case 2 A 15-year-old girl with Class I occlusion, normal skeletal sagittal maxillomandibular relationship. Palatally retained maxillary left canine. Maxillary midline displacement 2 mm to the left. Apart from space deciency for the maxillary left canine there is adequate space in both arches. Incisor inclination is normal. The soft tissue prole is normal, and will be unaffected by retaining teeth or by extraction. The patient is not concerned about the midline deviation and shows no interest in orthodontic treatment. As with case 1, on the basis of the above information and their diagnosis from the radiographs, the orthodontists were required to decide which tooth/teeth, if any, should be extracted. Case 3 A 13-year-old girl with Class I occlusion, normal maxillomandibular skeletal relationship and ectopic maxillary canines. The left canine can be detected by palpation. The right lateral incisor is in a crossbite relationAngle Orthodontist, Vol 78, No 5, 2008

appropriately timed intervention should avoid root resorption on adjacent incisors. In some patients with impacted maxillary canines there is such a deciency of space that extraction is necessary. In this context, it is important to determine the possible presence and severity of resorption of the roots of the adjacent incisors. When conventional computed tomography (CT) imaging is applied to supplement intraoral and panoramic radiographs of ectopically positioned maxillary canines, incisor root resorption is disclosed in almost 50% of cases.12 However, CT was not originally developed for 3D dental diagnostic application and, most importantly, this technique has been used only occasionally, because of the high radiation exposure. Instead, limited cone beam CT has been introduced for dental use,13 and this technique has proved successful for 3D diagnosis not only of impacted teeth14 but also for diagnosis of periapical pathology.15 The goal of case assessment and decision-making is to optimize patient outcomes. Providing treatment alternatives implies an interactive process whereby the knowledge and experience of the clinician is supported by the scientic evidence. One means of improving the decision-making process is to study the response of clinicians to well-dened tasks with respect to specic, representative case histories. The aim of this study was to evaluate or identify factors involved in the orthodontists decision-making in management of eruption disturbances of maxillary canines. MATERIALS AND METHODS Study Base The study base comprised all specialists and active members of the Swedish Orthodontic Society with current e-mail and postal addresses in the roster of the Swedish Orthodontic Society. Those eligible for participation met the following criteria: age 65 years, at least 1 years specialist experience and treating orthodontic patients in the public dental service, and in private practice or at a university clinic in Sweden. Specialists working predominantly with syndromes, cleft palate patients or administration, were excluded. Thus, 182 orthodontists were selected in the initial sample: 94 men (mean age 54.6 years, SD 8.04, range 30.0 65.0 years) and 88 women (mean age 52.8 years, SD 8.15, range 33.065.0 years). During September 2005, three case histories were sent by regular mail and e-mail to the eligible orthodontists. The case histories were accompanied by a questionnaire. To ensure optimal reproduction of the radiographs to be used in case assessment, these were sent electronically. Those who had not responded within 3 weeks were sent a reminder, and if no

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Figure 1. Panoramic and six intraoral periapical radiographs from a 12-year-old boy with Class I occlusion, severe space deciency in both jaws, mandibular right rst premolar extracted. Neither of the maxillary canines is clinically palpable. Normal skeletal maxillomandibular relationship and normal soft tissue prole.

ship. The left rst premolar is rotated buccomesially. Normal inclination of the maxillary incisors but lower incisors are retroclined. Normal soft tissue prole. As with the previous two cases, on the basis of this information and their assessment from the radiographs, the orthodontists were required to compile a treatment plan for the patient. As with case 1, supplementary CT information was then provided, namely root resorption has been detected in the apical quar-

ter of both maxillary left and right lateral incisors. On the right lateral incisor the resorption reaches half-way to the pulp, the resorption on the left lateral is more extensive but does not reach the pulp. The orthodontists were required to review their original treatment plan in light of this new complication and decide whether to leave the initial treatment plan unchanged or to change it, and if extraction was recommended, to nominate which tooth/teeth.

Table 1. Case 1 A 12-year-old Boy with Class I Occlusion, Normal Maxillomandibular Skeletal Relationship, and Maxillary Canines in Ectopic Positions. The Canines Are not Palpable. Severe Space Deciency in the Maxilla. The Mandibular Right First Premolar Has Already Been Extracted. The Soft Tissue Prole is Normal. Question: Which Tooth/teeth, if any, Would You Recommend for Extraction? Extraction of both Maxillary First Premolars n Recommendation based on panoramic and intraoral radiographs only Recommendation based on panoramic and intraoral radiographs and CT investigation 150 62 % 95.5 39.5 Extraction of both Maxillary Lateral Incisors n 71 % 45.2 Extraction of both Maxillary First Premolars and Maxillary Left Lateral Incisor n 15 % 9.6

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Figure 2. Panoramic, intraoral periapical and intraoral occlusal radiographs from a 15-year-old girl. Palatally retained maxillary left canine, space deciency for maxillary left canine, maxillary incisors 2 mm to the left, maxillary anterior spacing, and Class I occlusion.

Questionnaire The questionnaire comprised eight questions, about gender, age, number of years of specialist practice, whether in public or private practice, whether practicing in an urban or regional setting, the number of orthodontists at the clinic, and the frequency of therapy meetings. The participants were also asked how many ectopic maxillary canines they diagnosed and treated in a year and if they had access to CT.

Statistical Methods All data were analyzed using SPSS (version 14.0). Chi-square test was used to determine differences between categorical variables, while t-test was used to test the signicance of mean differences for continuous variables with approximately normal distributions. Mann-Whitney U-test was used for continuous variables not normally distributed. Signicance was set at P .05.

Table 1. Extended

Extraction of both Maxillary Canines n 3 3 % 1.9 1.9

No Extraction n 4 2 % 2.6 1.3

Extraction of Maxillary Left Canine Incisor n 1 % 0.6

Extraction of Maxillary Right Lateral Incisor n 1 % 0.6

Extraction of Maxillary Left Lateral Incisor n 1 % 0.6

Extraction of both Maxillary First Premolars and Maxillary Right Lateral Incisor n 1 % 0.6

Total n 157 157

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Figure 3. Panoramic and intraoral periapical radiographs from a 13-year-old girl. Both maxillary canines retained in ectopic positions, the left maxillary canine is palpable palatally, maxillary right lateral incisor in crossbite, space deciency both jaws, and Class I occlusion.

RESULTS Response Rate The response rate was 86.3%, yielding a nal sample of 157 participants, mean age 53.8 years (SD 8.12, range 30.065.0 years): 83 (52.9%) were men and 74 (47.1%) women. The average age was 54.0 years (SD 8.12, range 30.065.0 years) for the men and 53.0 years (SD 8.50, range 33.065.0 years) for the women. The 25 who failed to respond comprised 11 men and 14 women with a mean age of 59.0 years (SD 4.88) and 52.2 years (SD 6.19), respectively. Analysis disclosed no signicant differences between responders and nonresponders with respect to age, gender, or years as a specialist.

Main Results In all three cases, the orthodontists presented similar proposals for treatment plans based on the panoramic and intraoral radiographs and status and anamnesis provided in the text. In this context it is of interest to note that 61 of the participants commented that they could have referred the patients for supplementary CT investigation before the treatment plan was nalized. General agreement on the initial treatment plans notwithstanding, greater interclinician variation was observed with respect to the revised treatment plans for cases 1 and 3 following disclosure by CT of root resorption half-way to the pulp or more on the lateral

Table 2. Case 2 A 15-year-old Girl with Maxillary Left Canine Retained Palatally. Class I Occlusion and Spacing in Maxillary Anterior Area, Maxillary Midline is 2 mm to the Left; Space Deciency for the Retained Canine. The Patient was Not Interested in Orthodontic Treatment and Not Concerned about Her Maxillary Midline Deviation. Would You Recommend Extraction of any Tooth/teeth, and if so Which Tooth/teeth? Extraction of Maxillary Left Canine n Recommendation based on panoramic and intraoral radiographs 107 % 68.2 Extraction of Maxillary Left First Premolar n 7 % 4.5 Extraction of Both Maxillary First Premolars n 3 % 1.9 Extraction of Maxillary Left Second Premolar n 2 % 1.3

No Extraction n 31 % 19.7

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857 cases of ectopic maxillary canines presenting for treatment. In clinics with therapy meetings every week or when necessary, orthodontists more frequently recommended extraction of the lateral incisors rather than the rst premolars. The orthodontists encountering 1120 new cases of ectopic maxillary canines annually were less inclined to extract the lateral incisor than those seeing 10 or 21 such cases. Case 2 For this case there were 11 different suggestions of teeth for extraction. In most cases (73.8%) extraction of the maxillary left canine was suggested (Table 2). There was a greater tendency for nonextraction treatment or extraction of the left rst premolar among orthodontists with 1620 years specialist experience than those with 15 or 21 years of specialist experience. Case 3 In the initial treatment plan, the overwhelming majority (91.1%) of the orthodontists proposed nonextraction treatment. Extraction of the rst premolars was suggested by 8.3%, while one participant proposed removal of the maxillary left canine (Table 3). After CT disclosed root resorption on both the maxillary lateral incisors, 23.4% of the orthodontists proposed changes to their initial treatment plan, while 76.6% retained their original plan. This means that the number of orthodontists recommending nonextraction treatment decreased from 143 (91.1%) to 124 (79.0%). There were no proposals to extract the rst premolars or the canine but 33 (21%) proposed extraction of the lateral incisors (Table 3). There were no signicant associations between the decision-making and any of the eight variables, gender, or age. Sixty-one of the orthodontists had access to CT. DISCUSSION The response rate to the questionnaire was high (86.6%), and the results are therefore representative

incisor. Various teeth were recommended for extraction (Tables 1 and 2), but almost half the participants did not alter their initial recommendation to extract the rst premolars or not to extract at all. No relationship was found between decision-making and age, gender, number of years as a specialist, whether a public or private specialist in urban or regional area, or the number of orthodontists at the clinic. On the other hand, a trend but no clear association was found between decision-making and the level of clinical experience of treating ectopically erupted canines, or frequency of therapy meetings. Orthodontists treating 1120 cases of ectopic maxillary canines annually were more inclined to recommend extraction of the rst premolars than damaged lateral incisors, compared to those treating 110, or more than 21 cases a year. Orthodontists from clinics where meetings were held every second week, or more frequently when necessary, were more likely to recommended extraction of damaged lateral incisors than those reporting therapy meetings weekly, monthly, or seldom to never. Case 1 Extraction of the maxillary rst premolars was preferred by 95.5% of the orthodontists; 1.9% proposed extraction of both maxillary canines and 2.6% recommended nonextraction treatment (Table 1). Following the disclosure by CT of resorption halfway to the pulp on the buccal aspect of the middle third of the root of the left lateral incisor, there was increased variation with respect to teeth recommended for extraction: 61% changed their extraction recommendation (Table 1). Forty-four percent of the male orthodontists proposed extraction of the rst premolars and the same number proposed extraction of the lateral incisors. Among female orthodontists 39.4% preferred extraction of the rst premolars and 52.1% extraction of the lateral incisors. The differences between male and female orthodontists were, however, not signicant. There were signicant differences when the decision-making was related to frequency of therapy meetings in the clinic and annual number of new
Table 2. Extended

Extraction of Maxillary Extraction of Extraction of Maxillary Right Second Premolar Maxillary Right Extraction of Maxillary Right Extraction of Extraction of Maxillary Right First Premolar and Maxillary Left Second Second Premolar and Maxillary Right Right First Premolar and and Maxillary Left Canine Premolar Maxillary Left First Premolar First Premolar Maxillary Left Canine Second Preolar n 2 % 1.3 n 1 % 0.6 n 1 % 0.6 n 1 % 0.6 n 1 % 0.6 n 1 % 0.6 Total 157

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Table 3. Case 3 A 13-year-old Girl with Class I Occlusion, Ectopic Position of both Maxillary Canines, Right Lateral Incisor in Crossbite, Slight Space Deciency in both Jaws, and Palatally Retained Left Canine. Would You Suggest Extraction of any Maxillary Tooth/teeth, and if so Which Tooth/teeth? Extraction of Both Maxillary Lateral Incisors n 33 % 21.0 Extraction of Both Maxillary First Premolars n 13 % 8.3 Extraction of Maxillary Left Canine n 1 % 0.6

No Extraction n Recommendation based on panoramic and intraoral radiographs only Recommendation based on panoramic and intraoral radiographs and CT investigation 143 124 % 91.1 79.0

Total n 157 157

of treatment approaches by Swedish orthodontists to disturbances of eruption of maxillary canines. Although the validity of results from self-reported data can always be questioned, similar studies have shown that such data have good validity at the population level.16 In addition, analysis of the nonresponders disclosed no signicant differences between responders and nonresponders with respect to age, gender, or years of specialist experience. However, respect for personal integrity precluded more detailed comparison of the two groups. To date, there are no published studies of orthodontists decision-making in treatment of eruption disturbances of maxillary canines in which there may be associated resorption of the incisors. A major nding in this study was that while there was general consensus with respect to treatment plans based on conventional radiography, when CT disclosed root resorption half-way to the pulp or more on the lateral incisor, the orthodontists applied different approaches to treatment. This lack of consensus in more complex cases of eruption disturbances of maxillary canines has implications for orthodontic patients in the form of leaving severely resorbed incisor roots. Overall, there is very little information in the literature about the long-term status of incisors with resorbed roots. Becker and Chaushu17 found in 11 patients that resorption did not progress after treatment and all teeth remained vital. In a study by Bjerklin and Ericson18 on 80 patients with ectopically retained maxillary canines, the treatment plans were changed in 43% of the cases after additional information from a CT investigation. Thus, without the CT information, 11 lateral incisors with undiagnosed severe root resorption would have been left in situ. The question arises, however, as to the long-term fate of a deliberately retained incisor with root resorption, and moreover the consequences of subsequent application of orthodontic forces to such a tooth. It is recognized that almost 50% of cases of root resorption associated with ectopically positioned maxillary canines cannot be detected on conventional raAngle Orthodontist, Vol 78, No 5, 2008

diographs, indicating the need for CT investigation.19 However, only 61 of the orthodontists have access to CT as a diagnostic tool. Thus, orthodontists are aware that many incisors with undisclosed root resorption have been subjected to orthodontic forces. This may explain why proportionally many Swedish orthodontists still suggested extracting premolars and leaving severely resorbed incisors in situ under the conditions typied by cases 1 and 3 (Tables 1 and 3). There are no publications in the international literature on this topic, but it may be assumed that for various reasons, eg, practical and nancial, similar conditions apply in many other countries. In case 2 (Figure 2), a majority of the orthodontists (68.2%) proposed extraction of the canine without any follow-up orthodontic treatment. It is of interest to note that almost 20% preferred a nonextraction approach and the remaining 19 orthodontists suggested extraction of 1 or 2 teeth followed by orthodontic treatment, even though the patient was not interested in orthodontic treatment (Table 2). Apparently, as many as 19 orthodontists wanted to perform an extraction treatment with xed appliances despite the fact that the patient was not interested in orthodontic treatment. It can be questioned why these orthodontists wanted to do orthodontic treatment against the patients wish. Most of the orthodontists, however, recommended removal of the retained canine, probably because of the potential risk of damage to the adjacent teeth/ roots. A search of the literature provides no evidence that it is possible to retain the canine without risk of resorption of the adjacent teeth. Based on the responses to eight questions, the possible association between decision-making and gender, age and practice prole was analyzed. However, no clear picture emerged and only small differences were found. It might be expected that orthodontists with great experience of cases of retained or ectopically positioned maxillary canines would propose treatment which differed from that proposed by orthodontists less experienced in such cases. A similar pattern would also have been expected among orthodontists

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4. Yang EY, Kiyak HA. Orthodontic treatment timing: a survey of orthodontists. Am J Orthod Dentofacial Orthop. 1998;113: 96103. 5. Jones ML, Armstrong R, Kostopoulou O, Brickley MR. Treatment strategies for lower third molars following orthodontic care. Br J Orthod. 1997;24:319324. 6. Dachi SF, Howell FV. A survey of 3874 routine full mouth radiographs. II. A study of impacted teeth. Oral Surg Oral Med Oral Pathol. 1961;14:11651169. 7. Thilander B, Jakobsson SO. Local factors in impaction of maxillary canines. Acta Odontol Scand. 1968;26:145168. 8. Kramer RM, Williams AC. The incidence of impacted teeth. A survey at Harlem Hospital. Oral Surg. 1970;29:237241. 9. Thilander B, Myrberg N. The prevalence of malocclusion in Swedish school children. Scand J Dent Res. 1973;81:12 20. 10. Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol. 1986;14:172176. 11. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. Eur J Orthod. 1986;8:133140. 12. Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines. A CT study. Angle Orthod. 2000; 70:415423. 13. Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol. 1999;28:245248. 14. Nakajima A, Sameshima GT, Arai Y, Homme Y, Shimizu N, Dougherty HSr. Two- and three-dimensional orthodontic imaging using limited cone beam-computed tomography. Angle Orthod. 2005;75:895903. 15. Lofthag-Hansen S, Huumonen S, Grondahl K, Grondahl HG. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:114119. 16. Kronstrom M, Palmqvist S, Eriksson T, Soderfeldt B, Carls son GE. Practice prole differences among Swedish dentists. A questionnaire study with special reference to prosthodontics. Acta Odontol Scand. 1997;55:265269. 17. Becker A, Chaushu S. Long-term follow-up of severely resorbed maxillary incisors after resolution of an etiologically associated impacted canine. Am J Orthod Dentofacial Orthop. 2005;127:650654. 18. Bjerklin K, Ericson S. How a computerized tomography examination changed the treatment plans of 80 children with retained and ectopically positioned maxillary canines. Angle Orthod. 2006;76:4351. 19. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofacial Orthop. 1987;91:483492.

in clinics with many orthodontists or clinics which often held therapy meetings. A study is warranted of long-term follow-up of patients treated for ectopically positioned maxillary canines when incisor root resorption had not been detected at the start of treatment. A disadvantage of the present study is that the decision-making was based only on the information from the radiographs, anamnesis and status, without a clinical evaluation. However, practical and nancial considerations precluded clinical evaluation of the patients: instead, the three cases selected were typical of those frequently encountered in clinical orthodontic practice. CONCLUSIONS The treatment plans based on panoramic radiographs, intraoral radiographs, and status and anamnesis information were similar among the orthodontists. When supplementary CT information (root resorption half-way to the pulp or more on the lateral incisor) was provided, the orthodontists adopted varying approaches to their decision-making; this lack of consensus can have implications for orthodontic patients. The gender, age, and practice prole of the orthodontists had little association with their decisionmaking. ACKNOWLEDGMENTS
The authors would like to thank the participating orthodontists for their contribution to the study.

REFERENCES
1. Eddy DM. Clinical decision making: from theory to practice. Anatomy of a decision. JAMA. 1990;263:441443. 2. Ribarevski R, Vig P, Vig KD, Weyant R, OBrien K. Consistency of orthodontic extraction decisions. Eur J Orthod. 1996;18:7780. 3. Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: Part 1Interclinician agreement. Am J Orthod Dentofacial Orthop. 1996;109:297309.

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