ORIGINAL ARTICLE

Palatally impacted canines: A new

3-dimensional assessment of severity
based on treatment objective
Kinan G. Zenoa and Joseph G. Ghafaria,b,c
Beirut, Lebanon and Philadelphia, Pennsylvania

Introduction: The severity of a palatally impacted canine (PIC) is gauged radiographically on 2-dimensional and
3-dimensional positional components: eg, angulation and height. We hypothesized that the position of a PIC
relative to its virtual alignment in the arch is a better indication of impaction severity and treatment
requirements. The aims of this research were to evaluate variations in PIC location on 3-dimensional images
and to determine positional components associated with impaction severity. Methods: Linear and angular mea-
surements of 38 PICs from 28 cone-beam computed tomography scans were made on the panoramic, coronal,
sagittal, and axial sections. Measurements included angulation of the PIC to the virtually aligned canine, midline,
and palatal plane; and distances between cusp tip and apex to various reference planes—eg, occlusal and
midpalatal. Statistical assessments comprised t tests for group comparisons based on PIC and virtually
aligned canine severity (cutoff at 30 ) and Pearson product moment correlations for associations among
variables. Results: Angulations of the PIC to the virtually aligned canine were 32.5 6 15.5 (range, 9 -59 )
and 19.6 6 6.9 and 45.37 6 9.6 , respectively, in the less severe and more severe groups (P \0.001). Group
differences were significant (0.023 \P \0.001) for the apex and cusp distances between PICs and virtually
aligned canines and to the midline reference planes, and for PIC angulations to the palatal plane and midline.
Correlations were highest (0.7 \r \0.9; P \0.001) among PIC angulations to virtually aligned canines and to
midline planes (panoramic and coronal sections), and cusp to midline distances (panoramic and axial views).
Conclusion: A novel measurement of PIC inclination to its virtual aligned position indicates medial inclination
of the most severe PIC with the crown farther from the alveolar crest and the apex more posterior. The crown
varied over a wider range in the transverse plane; the apex varied over a comparatively narrower track antero-
posteriorly. (Am J Orthod Dentofacial Orthop 2018;153:387-95)

T
he most frequently impacted teeth after the third (3D) assessment, other critical factors include the applied
molars are the maxillary canines (1%-3%), with surgical procedure (also associated with the tooth posi-
most of them in a palatal position.1 The variations tion), the amount and quality of the covering bone, and
in buccopalatal, vertical, and anteroposterior locations the traction mechanics including active force compo-
of impaction define treatment complexity and duration. nents and anchorage setup.
Although severity of impaction and associated treatment The various methods to determine impaction severity
difficulty are primarily ascribed to this 3-dimensional and relate it to treatment difficulty originated because of
2 major therapeutic side effects: the extended duration
of orthodontic treatment2-4 and the resorption of
a
Division of Orthodontics and Dentofacial Orthopedics, American University of adjacent teeth, particularly lateral incisors, reported in
Beirut Medical Center, Beirut, Lebanon.
b
Department of Orthodontics, American University of Beirut, Beirut, Lebanon; nearly 50% of patients with a palatally impacted
Department of Orthodontics, Faculty of Dental Medicine, Lebanese University, canine (PIC)5,6 and related to unduly sustained forces
Beirut, Lebanon. in a protracted treatment.
c
Department of Orthodontics, University of Pennsylvania, Philadelphia.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- Based mostly on 2-dimensional (2D) radiographs
tential Conflicts of Interest, and none were reported. (periapical, intraocclusal, and panoramic), PIC severity
Address correspondence to: Kinan G. Zeno, Division of Orthodontics/Dentofacial has been stratified on positional components (horizon-
Orthopedics, American University of Beirut Medical Center, PO Box 11-0236 Riad
El-Solh 1107 2020, Beirut, Lebanon; e-mail, [email protected]. tality, angulation, height). Ericson and Kurol7 classified
Submitted, March 2017; revised and accepted, July 2017. severity through cusp tip position in sectors drawn to
0889-5406/$36.00 the adjacent lateral and central incisors: impactions
Ó 2017 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.07.020 mesial to the lateral incisors are more severe than those

387
388 Zeno and Ghafari

in a more distal position. Stewart et al4 associated canine after treatment. See Supplemental Materials
severity and ensuing treatment time with the vertical for a short video presentation about this study.
distance of the cusp tip to the occlusal plane at a
threshold of 14 mm. Pitt et al8 determined that the ca- MATERIAL AND METHODS
nine's horizontal position, vertical height, buccopalatal Our material comprised CBCT scans of 28 patients
position, and the patient's age projected severity and (mean age, 16.06 6 4.9 years; 16.9 6 4.9 years for
treatment difficulty. Crescini et al9 found that every in- male subjects, 15.7 6 4.9 years for female subjects) who
crease of 5 in the angle between the PIC and the midline had 38 PIC s (18 unilateral, 10 bilateral) and sought ortho-
resulted in 1 additional week of treatment. These ap- dontic treatment at the American University of Beirut
proaches have not been compared in controlled studies Medical Center in Beirut, Lebanon. The scans were pre-
and have not provided consistently predictable out- scribed for accurate localization of the impacted canines
comes in patients. In addition, 2D radiographs cause var- after a clinical examination that included an initial diag-
iable distortions of anatomic dimensions and nostic panoramic or periapical radiograph. This retrospec-
overestimated measurements, particularly patient posi- tive study was approved by the institutional review board.
tioning errors during radiography.10,11 CBCT scans were selected according to the following
Although concerns for excessive radiation initially criteria.
limit the use of 3D imaging methods, including cone-
beam computed tomography (CBCT), the risk is reduced 1. Presence of unilateral or bilateral PIC. Canines had
by imaging the specific canine area. New indexes were been considered at higher potential for impaction
developed to predict impaction potential. Kau et al12 when they have not erupted into the oral cavity by
calculated a “KPG” index by adding the scores assigned the age of 13 years (1 year after the normal maxillary
to cusp tip and root tip in the 3 planes of space on the permanent canine eruption age range of 11-
CBCT panoramic and axial sections. Alqerban et al13 12 years15) and at the clinical examination, they
determined that the strongest predictors of impaction were not palpable in the vestibule, prompting
were the PIC's angulation to the lateral incisor, the dis- further radiographic confirmation. Within this
tance to the occlusal plane, and the crown position rela- scheme, 2 girls whose initial regional CBCT scans
tive to the arch and adjacent teeth. were taken at ages 10 and 11 were included in the
The 3D methods have not yielded more definitively study; they were treated nearly 1 year later with
predictive information. Haney et al14 determined that exposure of the canine and then with orthodontic
CBCT changed 2D-based diagnosis and treatment plan- traction into the arch. A subsequent preexposure
ning of impacted canines in 27% of the evaluations. CBCT scan was not taken to minimize radiation;
Although occurring in a relatively low percentage, this the tooth was followed with periapical radiography.
difference may be critical for an individual patient 2. CBCT scans of good quality and sufficient field of
and indicates the need to further explore variations of view covering at least half of the maxilla.
PICs in 3D imaging to improve the assessment of The exclusion criteria were craniofacial anomalies or
impaction severity and in the future its link with treat- syndromes and x-rays with limited field of view or low
ment outcomes. resolution that precluded accurate measurements.
In this article, we introduce a new scheme for Linear and angular measurements, recorded using the
severity assessment based on projected treatment Ez3D Plus 3D CDViewer software (version 1.2.6.6; Vatech
outcome. Accurate determination dictated the reliance Global, Gyeonggi-do, Korea), included the following.
on 3D CBCT images. We hypothesized that the assess-
ment of the PIC relative to its virtual posttreatment 3. On the panoramic section (Fig 2), PIC/VAC angle,
correction would better reflect the severity of impac- defined by the intersection of the axis of the
tion by personalizing the impaction to the patient. impacted canine and the simulated aligned tooth
To this end, we defined the “virtually aligned canine” between the adjacent teeth (lateral incisor and first
(VAC) as the simulated aligned tooth in its final post- premolar), determined by drawing a vertical line
treatment position in the arch to determine its posi- parallel to these teeth or along the long axis of the
tion in all planes of space (Fig 1). Accordingly, the primary canine if present. Other measurements
aim of this study was to determine, based on 3D im- included the cusp tip to occlusal plane vertical dis-
ages of PICs, the positional components associated tance, distances between cusp tip and apex to the
with impaction severity in relation to treatment objec- midline, and the PIC angulation to the midline.
tive, not only diagnostic features. Treatment objective 4. On the coronal section (Fig 3, A), the PIC angulation
was defined as the simulated end position of the to the midline.

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Zeno and Ghafari 389

Fig 1. Three-dimensional rendition of a CBCT image illustrating virtual alignment of the right PIC (red)
as a VAC (turquoise) positioned within the dental arch. The dotted yellow lines indicate the distances
between the original and simulated apices and cusp tips when the PIC is moved to its corresponding
VAC.

Fig 2. Panoramic view illustrating on the patient's left side the angle (1) between the PIC and the cor-
responding VAC, and the inclination of the PIC to the midline (angle 2). On the right side, the measured
distances (mm) are A, the vertical distance between the cusp tip to the occlusal plane, and the horizon-
tal distances between B, cusp tip and C, apex to the midline.

5. On the axial section (Fig 3, B), cusp tip and apex de- visible relative to the reference lines, the measure-
viations, the transverse projections of the respective ments were obtained by scrolling to the section that
distances between the cusp tips and apices of the contained the apex or the crown tip. The projection
PIC and VAC; distances between the cusp tip and of the apical point or the cusp tip was marked on
apex to the midpalatal plane and distance between the pertinent section once identified; the distances
the mesial aspect of the first molar to prosthion between the targeted points were automatically pro-
(most anterior point on the alveolar bone crest). vided by the software.
6. On the sagittal section (Fig 3, C), PIC angulation to Two subgroups of 18 and 20 teeth (Table I) each were
palatal plane, cusp tip to occlusal plane (vertical categorized based on the severity of the angle PIC/VAC.
projection), and the anterior projection of the cusp The cutoff was set at a realistic threshold of 30 , nearly
tip to the frontal plane through prosthion. one third of the angle (about 80 ) between a normally
inclined canine (about 11 ) and the most severe possibil-
On the axial and sagittal views involving the apex ity of a totally horizontal impaction (0 to the palatal
and cusp tip, whereby both were not simultaneously plane).

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390 Zeno and Ghafari

Fig 3. Position of the PIC of 1 subject in different planes of space: A, angulation to the midline on the
coronal section; B, cusp tip and apex deviations: cusp and apex distances to the midline on the axial
section; C, angulation to the palatal plane (PP), vertical distance to occlusal plane, and anterior dis-
tance to prosthion (Pr) on the sagittal section. On the axial and sagittal views, the apex and cusp tip
are not visible simultaneously relative to the reference lines; the distances were measured after scroll-
ing to the section that contains the apex or the crown tip and marking them. The measurements reflect
the projection of the marked apical points or cusp tips. Note in B that the current scroll is at the level of
the cusp tip of the PIC.

Table I. Positional components of PIC in severity subgroups stratified on inclination between PIC and VAC
Total sample PIC/VAC \30 PIC/VAC .30
n 5 38 n 5 18 n 5 20

Mean SD Mean SD Mean SD P*

Patient age (y) 16.1 4.9 14.7 3.0 17.3 6.0 0.103
Panoramic view
PIC/VAC ( ) 32.5 15.5 19.0 6.6 43.6 9.9 \0.001*
Vertical (mm)a 9.5 2.3 8.5 2.2 10.3 2.1 0.016*
Cusp to midline (mm)b 6.8 3.9 9 3.5 4.8 3.2 \0.001*
Apex to midline (mm)c 19.4 2.6 18.3 2.0 20.3 2.7 0.011*
PIC to midline ( )d 35.1 15.4 22.6 9.8 46.4 9.6 \0.001*
Sagittal view
Anterior (mm) 9.1 2.0 9.5 2.6 8.8 1.2 0.258
Vertical (mm)a 10.4 2.3 9.7 2.2 11.0 2.3 0.098
PIC to palatal plane ( ) 110.6 13.1 103.6 9.0 116.9 13.3 0.001*
Axial view
Cusp deviation (mm) 11.1 3.3 9.9 2.8 12.2 3.2 0.023*
Apex deviation (mm) 8.2 2.3 7.1 2.0 9.2 2.2 0.003*
Cusp to midline (mm)b 4.9 3.0 6.5 2.6 3.5 2.7 0.001*
Apex to midline (mm)c 14.8 1.7 14.5 1.4 15.1 2 .0 0.333
First molar to midpalatal plane (mm) 16.6 2.0 16.5 1.8 16.6 2.3 0.900
First molar to prosthion (mm) 34.5 2.8 35.5 2.3 33.5 2.7 0.027*
Coronal view
PIC to midline ( )d 27.4 15.18 17.2 11.9 36.7 11.6 \0.001*
a, b, c, d, Differences in each severity group between measurements of positions on the panoramic view and similar measurements on other views (a
on sagittal, b and c on axial, d on coronal) were gauged by t tests: all were statistically significantly different (0.015 \r \0.001) except the vertical
distance (a) in the high severity group (P 5 0.122).
*P value for comparisons between severity groups; statistically significant at P \0.05.

Statistical analysis correlation coefficient was used to explore associations

Statistics included descriptive computations, based among variables. To test which variables would predict
on the angulation severity of the subgroups, as well as the severity of the PIC/VAC angulation, associations be-
bivariate and multivariate analyses. The Pearson tween the latter, positional variables, and age were

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 American Journal of Orthodontics and Dentofacial Orthopedics

Zeno and Ghafari

Table II. Correlations among positional parameters of PIC in various planes of space (only statistically significant correlations are given; P values are in pa-
rentheses)
Panoramic Axial plane Coronal Sagittal

First
Cusp to Apex to PIC/ Cusp Apex Cusp to Apex to molar to PIC/palatal
Section Measurement Vertical midline midline midline deviation deviation midline midline prosthion PIC/ midline Vertical plane
Panoramic PIC/VAC ( ) 0.5 (0.001) 0.7 (\0.001) 0.4 (0.032) 0.9 (\0.001) 0.57 0.48 0.7 0.85 (\0.001) 0.3 (0.04) 0.6 (\0.001)
(\0.001) (0.002) (\0.001)
Vertical 0.5 (0.001) 0.4 (0.011) 0.7 (\0.001)
(mm)
Cusp to 0.8 (\0.001) 0.6 0.8 0.4 (0.015) 0.8 (\0.001) 0.5 (0.003)
midline (\0.001) (\0.001)
(mm)
Apex to 0.5 (0.004) 0.3 0.7 0.4 (0.025)
midline (0.045) (\0.001)
(mm)
PIC/ 0.6 0.5 0.7 0.9 (\0.001) 0.6 (\0.001)
midline ( ) (\0.001) (0.002) (\0.001)
Axial Cusp 0.37 0.7 0.67 (\0.001) 0.46 (0.004)
deviation (0.02) (\0.001)
(mm)
Apex 0.62 (\0.001)
deviation
(mm)
Cusp to 0.39 (0.017) 0.86 (\0.001) 0.35 (0.03)
March 2018  Vol 153  Issue 3

midline
(mm)
First molar 0.7 (\0.001)
to midline
(mm)
Coronal PIC/midline 0.32 (0.05) 0.37 (0.02)
( )

391
392 Zeno and Ghafari

evaluated using multivariate regression analysis. To

Table III. Multivariate regressions of variables predict-
determine intraexaminer reliability, an author (K.Z.)
ing PIC/VAC angle
repeated all measurements on 10 CBCT radiographs at
least 14 days after the initial assessment. The measure- Associated variables Coeffficient SE 95% CI P value
ments were evaluated with the 2-way mixed-effects in- PIC/midline 0.923 0.173 0.57, 1.28 \0.001*
traclass correlations for absolute agreement on single (coronal)
PIC/palatal plane 0.447 0.874 0.24, 0.65 \0.001*
measures. Statistical significance was set at P \0.05.
(sagittal)
SPSS software (version 20.0; IBM, Armonk, NY) and Constant 42.83 26.505 97.12, 11.46 0.878
Stata software (version 11.1; StataCorp, College Station, F (9, 28) 19.69
Tex) were used for all statistical analyses. Prob . F \0.001
R2 0.864
Adjusted R2 0.820
RESULTS
Multivariate equation to predict PIC/VAC angle:
The intraclass correlation coefficients gauging reli- X 5 0.92*(PIC-midline-coronal ) 0.45*(PIC/palatal plane-sagittal)
ability of repeated measurements were high, ranging 42.8.
from 0.91 to 0.997, except for the anterior distance in X: PIC=VAC angle.
*Statistically significant at P \0.05.
the sagittal plane (r 5 0.80).
The male-to-female ratio of patients with PIC was
1:2.5. The range of the PIC/VAC angle was 9 to 59 ,
and its mean in the total sample was 32.47 6 15.46 Table IV. Multivariate regressions of linear variables
(19 6 6.6 and 43 6 9.9 in the lower and higher predicting PIC/VAC angle
severity subgroups, respectively; P\0.001; Table I). Dif- Associated variables Coefficient SE 95% CI P value
ferences between these subgroups were statistically sig- Vertical position 1.655 0.669 0.29, 3.02 0.02*
nificant for various parameters: the inclination to the (panoramic)
palatal plane (sagittal, P \0.001), apex and cusp dis- Apex deviation (axial) 1.957 0.685 0.56, 3.36 0.008*
tances between PIC and VAC (axial plane, P 5 0.023 Cusp-midline (axial) 1.990 0.960 3.95, 0.03 0.047*
and 0.003, respectively), apex to midline distance (pano- Constant 7.917 16.446 20.40, 46.77 0.429
F (7, 30) 13.21
ramic, P 5 0.011), and inclination to midline (coronal, Prob . F \0.001
P \0.001; panoramic, P \0.001) were all greater in R2 0.755
the high severity group. Adjusted R2 0.698
The cusp to midline distance was smaller in the higher Multivariate equation to predict PIC/VAC angle:
severity group (axial, P 5 0.001; panoramic, P \0.001), X 5 1.66*(vertical-panoramic) 1 1.96*(apex deviation) 1.99*(cusp-
reflecting the more medial position of the crown in this midline) 1 7.92.
group. The height of the cusp was on average similar be- X: PIC=VAC angle.
*Statistically significant at P \0.05.
tween the severity groups on the sagittal view (P 5 0.098)
but different on the panoramic view (P 5 0.016),
although the difference between the group means was (r 5 0.85) views, as well as PIC/VAC to the position of
less than 1 mm. The distance between the anteroposterior its cusp tip on the panoramic (r 5 0.7) and axial
position of the first molar and the interincisal point in the (r 5 0.7) views (Table II). The canine angulation to
axial view was smaller in the severe group compared with midline was significantly correlated to cusp tip devia-
the less severe group (P 5 0.027; Table I). tion (r 5 0.67) and cusp tip to midline (r 5 0.80 on
The measurements of similar positions on the pano- panoramic and r 5 0.86 on axial views) (P \0.001).
ramic view and other views—ie, the cusp tip to occlusal Moderate correlations (0.48 \r \0.57) were noted
plane vertical distances, distances between the cusp tip between PIC/VAC and the deviations of the canine
and apex to the midline, and the PIC angulation to the cusp and apex. The highest correlations for cusp devi-
midline—were statistically significantly different ation were with the cusp to midline distance
(0.015 \P \0.001); only the cusp tip to occlusal plane (r 5 0.7) and PIC angulation to midline on the axial
vertical distances between the severity groups measured view. The highest correlation for apex deviation was
on the panoramic and sagittal views were not different with the PIC angulation to the palatal plane
(Table I). (r 5 0.62).
The highest correlations were observed between Based on the regression analyses, the significant pre-
the angulations of PIC to VAC and the angulations dictors of the PIC/VAC value were the angulation to the
to the midline on the panoramic (r 5 0.9) and coronal midline in the coronal plane, and the angulation to the

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Zeno and Ghafari 393

Fig 4. Different impaction severity scenarios: graphic representation of the PIC in severe (red), mod-
erate (orange), and milder (yellow) configurations in the A, occlusal/axial plane, B, sagittal plane, and
C, coronal plane. Notable are the more distal apical and the more medial cuspal positions of the PIC in
the more severe group.

palatal plane in the sagittal plane, together explaining anteroposteriorly in a narrower track than that of the
82% of the variation in PIC/VAC (Table III). When testing cusp. The cusp and apex deviations between PIC and
only for linear measurements predictive of the PIC/VAC VAC reflected the projected transverse movement of
angulation, the apex deviation and cusp to midline dis- crown tip and apex to align the canine. The variation
tance in the axial plane, and the vertical position on the of the cusp tip path to the virtual corrected position
panoramic view together explained 70% of the PIC/VAC was greater than that of the apex (about a 3-mm dif-
variation (Table IV). ference in the means of the total sample and sub-
groups; Table I; Fig 4, A and B).
DISCUSSION 3. The simulated cusp and apex deviations from their
In the new assessment of PIC, 3 important observa- original to treated positions offer a unique clinical
tions were extracted from the results. translation of impaction severity. In the least severe
group, the deviations from PIC to VAC would
1. A severe impaction is associated with a more distal amount to an average of 1 cm for the crown and
apex and a more medial crown; it is thus a medial nearly 7 mm for the apex. Comparatively, corre-
inclination of the tooth (Table I; Fig 4). These com- sponding displacements in the higher severity group
ponents would dictate a longer trajectory of correc- (12.2 and 9.2 mm) would amount to about 20% and
tion. The crown of the more severely inclined PIC 30%, respectively, more than in the milder group
was nearly half the distance from the axial midline (Table I). Other factors affecting treatment outcome
(3.5 mm), and about twice more palatal than the (bone coverage, surgical procedures, mechanics)
cusp tip of the PIC in the less severe group might even compound traction difficulty in the
(6.5 mm; P \0.001). The cusp tip mean was closer more severe impactions.
to the anterior frontal plane in the milder severity
group, but it was not significantly different from These observations are additionally delineated by the
that of the higher severity group. correlations among variables. Cusp tip position correla-
2. The crown varied more in the transverse plane and in tions with the PIC path of correction (PIC/VAC to cusp
a wider range than did the apex; the apex varied more deviation, r 5 0.57; and cusp to midline, r 5 0.70)

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394 Zeno and Ghafari

were higher than the corresponding correlations with than the PIC, corroborating earlier 2D studies that indi-
apex deviation (PIC/VAC to apex deviation, r 5 0.48; cated the contribution of horizontality to impaction
and apex to midline, r 5 0.16), likely indicating that severity.8,9
cusp tip variations were associated more with the posi- The accurate position of the VAC may be questioned,
tion of impaction. However, the apical deviation (mostly particularly in malocclusions where space is needed to
anteroposterior) had its highest correlation with the align the canines, and in Class II malocclusions that
canine inclination to the palatal plane on the sagittal require distal movement of posterior teeth before canine
view (r 5 0.62) and along with the cusp midline (trans- displacement. Distal movement of the canine was not
verse) and cusp height (vertical) accounted for 70% of simulated and must be accounted for in each patient.
PIC/VAC variations (Table IV). As predictors of PIC/ The more mesial position of the maxillary permanent
VAC, these linear components covered all planes of first molars in the more severe PIC/VAC group (Table I)
space, underscoring the importance of 3D assessment. possibly indicates more crowding, such as mesial drift
In the comparison with other studies, although our into the impacted canine space or a Class II relationship.
findings support earlier conclusions from 2D analyses The distances between molars and the midpalatal plane
that buccopalatal position and inclination of PIC to were similar between groups. Research including space
midline are indicators of severity8,9 and corroborate 3D analysis on dental casts and corresponding radiographic
reports regarding the concert of variable cusp tip and measurements would be required to further elucidate
root tip positions to impaction severity,12,13 our study dental relationships.
also delineates the following important nuances. Linear measurements on the panoramic CBCT view
(cusp height, cusp to midline, apex to midline) were
1. The position of the apex at all levels of severity tends
mostly projections of corresponding more direct mea-
to be along an anteroposterior plane but more pos-
surements on other views (sagittal and axial) but were
terior in the more severe impactions (Fig 4).
not statistically significantly different from each other
2. The vertical position, used as a severity component
(Table I). This finding indicates the potential for using
in treatment difficulty indexes,4,8,12 was equally
the CBCT panoramic view for diagnostic purposes. How-
important in less and more severe groups
ever, if the CBCT record is available, the pertinent mea-
(P .0.05 in the sagittal view; P 5 0.011 but
surements are best evaluated on the other views rather
mean difference of less than 1 mm on the
than their projections on the panoramic section. The po-
panoramic view; Table I). However, the vertical pro-
tential for using 2D panoramic radiographs warrants
jection was a copredictor of severity, as found in
separate research, although the 3D record is favored
other investigations.4,8 We observed lower
over the 2D radiograph in comparative studies.14,19,20
averages for this height than the threshold
Nevertheless, the importance of 3D assessment in an
distance of 14 mm advocated by Stewart et al4 as
accurate diagnosis must be balanced with the careful
a cutoff for severity and treatment duration. The dif-
use of radiation exposure, which was restricted to the
ferences might be ascribed to the more accurate 3D
pertinent maxillary segment in our population.
images used in this study, without the magnification
in 2D panoramic radiographs in the other study.
CONCLUSIONS
The 1:2.5 male-to-female ratio of palatally impacted
canines coincides with the 1:2 prevalence reported 1. A novel measurement of PIC inclination to its simu-
earlier.16 The relationship of PICs to the adjacent lateral lated virtual aligned position reflects an effective
incisors provided an optimal assessment of severity in measure of impaction severity. This practical
previous 2D4,8,9,17,18 and later 3D12,13,19 studies. In our approach describes the problem in reference to the
model, this relationship was indirectly reflected in the needed treatment outcome, by reflecting the dis-
PIC/VAC angulations, particularly the most severe. tance needed to align the impacted canine.
The intraexaminer reliability was high based on most 2. The most severe or obtuse PIC was inclined to the
intraclass correlation coefficients (r .0.91), but lower for midsagittal plane (coronal view) with the canine
the anterior distance on the sagittal section (r 5 0.80), tip more medial and farther from the alveolar crest,
probably because of greater variability in reproducing and the apex more posterior. The position of the
the sagittal section; thus there was more variability in crown, which varies more buccopalatally, seems to
replicating the anterior reference plane through prosthion. determine severity more than the location of the
This research was restricted to palatal impaction, but apex, which varies on a more anteroposterior track.
during sample selection, the excluded buccally impacted These findings indicate a wider margin of displace-
canines were noted to assume more horizontal positions ment within bone for the crown than for the apex.

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Zeno and Ghafari 395

3. The delineation of the 30 cutoff for severity seems 9. Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Orthodontic
more realistic than higher cutoff angulations. and periodontal outcomes of treated impacted maxillary canines:
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ACKNOWLEDGMENT 11. Stramotas S, Geenty JP, Petocz P, Darendeliler MA. Accuracy of
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We thank Dr. Maria Saadeh for the statistical analysis. at various positions in vitro. Eur J Orthod 2002;24:43-52.
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system for canine impactions—the KPG index. Int J Med Robot
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Supplementary data related to this article can be for maxillary canine impaction. Am J Orthod Dentofacial Orthop
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American Journal of Orthodontics and Dentofacial Orthopedics March 2018  Vol 153  Issue 3