ISSN: 1110.

435X Egyptian
Orthodontic Journal
Morphological Features of Dentition Associated With Unilateral
Palatally Impacted Canine Using Cone Beam
Computedtomography:
An Etiological Study
Omar Okasha1; Essam Abdallah2; Tarek Nasr-eldin Yousry3

ABSTRACT Conclusion: Narrower interpremolar width,

increased canine volume, shorter root of lateral incisor
Introduction: the aim of this study is to
and increased length of canine crown are contributing
determine the morphological features of dentition
factors for impaction of the canine.
associated with unilateral palatally impacted
maxillary canine and to predict of the possible local Keywords: impacted canines, cone beam, canine
risk factors causing palatal impaction of the maxillary volume, maxillary dentition morphology.
canine. aMaster student, Orthodontic Department,
Materials and Methods: 45 cone beam computer Faculty of Dentistry, University of Alexandria.
tomography were collected of patients diagnosed with b Professor of orthodontics, Orthodontic
unilateral palatally impacted canines 11 males and 34
Department, Faculty of Dentistry, University of
females the mean age was 20.38 ± 4.37. The maxilla was
Alexandria
divided into two for a split mouth design.The following
c Lecturer of orthodontic, Orthodontic
parameters were obtained: The mesiodistal width of each
Department, Faculty of Dentistry, University of
tooth, the crown /root ratio of each tooth, and the volume
Alexandria
of the impacted canine compared to the contralateral
normally erupting canine, angulation and morphology of INTRODUCTION
the root, Interpremolar and intermolar width of the upper
Orthodontics is considered to be a
arch and the arch perimeter.The measures were compared
complex problem solving domain. A good
between the 2 sides. The data obtained in this study was
example of this is dealing with a large number
subjected to Kolmogorov-Smirnov test, McNemar test and
of factors and treatment options which must be
Paired t-test at P ≤0.05.
considered when dealing with impacted teeth.
Results: The results showed larger canine
Maverna and Gracco (2007)1 defined
volume, narrower interpremolar width and increased
Impaction as failure of eruption a tooth into the
crown root ratio of the laterals and canines on the
oral cavity within the right time of the normal
impacted side. There was no statistically significant
physiological process.
difference between two sides in the rest of the
measurements.

1
Postgraduate student, Orthodontic Dept, Faculty of Dentistry, Alexandria University
2
Professor of Orthodontics, Faculty of Dentistry, Alexandria University.
3
Assistant lecturer of Orthodontics, Faculty of Dentistry, Alexandria University.

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Impacted teeth have been a serious Congenitally missing maxillary teeth, (4)
problem for orthodontists, the decision whether Systemic diseases affecting growth and
to extract them or to drag them into occlusion eruption.
depends on several factors, and require The entire Cone beam computed
accurate diagnosis and treatment planning and tomography scanning data collected were
coordination between team of general dentist, saved in DICOM (digital imaging and
orthodontist, periodontist and surgeon. communications in medicine) format.
Palatally impacted canines is one of the most Professional medical image software,
common impacted teeth found it occurs in 1 OnDemand3DApp 1.0.9.3223; Module name
out 100 of people 2, 70-85% of impacted [M] DVR was used for tissue segmentation, 3D
canines are located in the palate 3while 15 % is
reconstruction, and volumetric measurement.
only located in the buccal side according to
The maxilla was separated from the
Jacoby 4.
mandible and the mandible was entirely cut
The Aim of the studyistodetermine the and removed from the field of view for
morphological features of dentition associated facilitation of measurements.
with unilateral palatally impacted maxillary
Measurements were made on 3D
canine. And to Predict of the possible local risk
reconstructed images of the maxillary dentition
factors causing palatal impaction of the
maxillary canine. The records were divided into two
quadrants: the impacted side and the normally
This will help identifying the subjects with
erupting side. The following parameters were
a high risk of unilateral palatal canine
obtained and compared:
impaction facilitating early interception.
1. The mesiodistal width of each tooth:
Materials and methods:
after viewing the maxilla from occlusal
The experiment was conducted in the direction oriented by the software and using
Faculty of Dentistry, Alexandria University. a 3D ruler for standardized measurments,
Forty five cone beam records were selected this was measured from the mesial anatomic
from either the records of the outpatient clinic contact point to the distal anatomic contact
of the Department of Orthodontics, Faculty of point of each tooth. (Fig 1.)
Dentistry, Alexandria University or from the
2. The crown /root ratio of each tooth:
CBCT records routinely used for diagnosis of
the CBCT was oriented to a lateral view by
impacted canines according to the following
the software, 3D ruler was used and the
criteria:Inclusion criteria: Patients with
crown/root ratio was measured by dividing
unilateral palatally impacted canines aged from
the anatomic height of the crown by the
14 to 25 years old.Exclusion criteria: (1)
length of the root (mm). (Fig 2.)
Congenital facial defects or disease affecting
growth according to the case history,(2) 3. Interpremolar and intermolar width
Previous orthodontic intervention, (3) of the upper arch: the interpremolar width
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Orthodontic Journal
is the linear measurement between the top of discarded. The mean of the two closest
the buccal cusp tips of the right and left measurements was used in the calculations.
maxillary first premolar and the midline
viewed from occlusal direction oriented by
the software and using a 2D ruler.

The intermolar width is a linear

measurement between the mesiopalatal cusp
tips of the right and left maxillary first
permanent molars and the midline viewed
from occlusal direction. (Fig3.)

4. Arch perimeter: this was measured

from the occlusal view using a 3D curve line Figure 1 Measuring mesiodistal
from the midline to the mesial contact point dimensions of the teeth
of the first permanent molars on both sides
and compared to each other. (Fig4.)

5. Angulation and morphology of the

root of the impacted canine compared to the
contralateral normally erupting canine: by
measuring the angle between the long axis of
the crown and the long axis of the root after
orienting the canine in a buccal view and
long axis of the crown perpendicular to the Figure 2 Measuring crown/root ratio of
floor, in addition to inspection of the teeth
dilacerations. (Fig5. & Fig6.)

6. The volume of the impacted canine

compared to the contralateral normally
erupting canine: this was measured using
the software (mm3) after separating each
canine separately and removing any
overlaying bone. . (Fig7. & Fig8.)

All measurements on CBCT were made

twice by the same examiner with one week
interval between the two measurements. If Figure 3 Measuring interpremolar and
the difference between the two intermolar distances
measurements is apparent, a third reading
will be made and the aberrant one

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Figure 7 Measuring canine volume on

the impacted side
Figure 4 Measuring arch perimeter on
both sides.

Figure 8 Measuring canine volume on

the normally erupting side

Sample size
By adopting a power of 95% to detect the
difference in canine volume as a primarily
Figure 5 Measuring canine angulation
outcome of 0.776 (medium-sized standardized
(root long axis in relation to crown long
effect size)5, and level of significance 95%
axis)
(α=0.05), the minimal required sample size was
found to be 246. When we adopt a smaller
standardized effect size equal to 0.50 the
minimal required sample size was found to be
45. Sample size do not need to be increased to
control for attrition (withdrawal) bias7.
Consecutive samplings were used till reaching
the required sample size.The sample size was
calculated using GPower version 3.1.9.2. 8
Figure 6 Presence of apical root hook

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Results:
This study was carried out on 45 cone
beam x-rays of patients with unilateral
palatally impacted canines. The mean age was
20.38 years ranging from 14 to 26 years. 34
patients were females and 11 were males
representing 75.6% and 24.4% respectively.

When comparing the mesiodistal

dimensions of the teeth on the impacted side
Figure 9 Comparison between the two
and normally erupting side, it was found that
studied periods according to mesiodistal
there was no statistically significant difference
dimensions
between the two sides.(fig 9)
When comparing the crown/root ratio of
the teeth on the impacted side and normally
erupting side, it was found that only crown/root
ratio of the maxillary lateral incisor and
canines showed significantly larger crown root
ratio on the impacted side. (Table I)

Table I Comparison between the two sides according to mesiodistal dimensions.

Cases Control
Crown root ratio t p
(n = 45) (n = 45)
1
Min. – Max. 0.02 –1.17 0.51 –1.13
Mean ± SD. 0.80 ±0.22 0.80 ±0.18 0.137 0.892
Median 0.79 0.79
2
Min. – Max. 0.42 –1.15 0.42 –1.03
Mean ± SD. 0.76 ±0.15 0.71 ±0.14 2.399* 0.021*
Median 0.75 0.71
3
Min. – Max. 0.45 – 0.95 0.42 –0.88
Mean ± SD. 0.68 ± 0.11 0.64 ±0.11 2.335* 0.024*
Median 0.67 0.64
4
Min. – Max. 0.36 –0.86 0.36 –0.90
Mean ± SD. 0.60 ±0.12 0.63 ±0.12 1.804 0.078
Median 0.62 0.62
5
Min. – Max. 0.35 –0.87 0.35 –1.11
Mean ± SD. 0.58 ±0.13 0.59 ±0.14 0.219 0.827
Median 0.57 0.57

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6
Min. – Max. 0.23 –0.80 0.01 – 1.55
Mean ± SD. 0.53 ±0.11 0.56 ±0.23 0.706 0.484
Median 0.52 0.51
7
Min. – Max. 0.35 –0.84 0.07 –1.12
Mean ± SD. 0.55 ±0.13 0.57 ±0.19 0.846 0.402
Median 0.52 0.55
t: Paired t-test
p: p value for comparing between the studied periods
*: Statistically significant at p ≤ 0.05

The crown and root lengths of the lateral incisor and canine were measured separately, The root of
the lateral incisor was shown to be significantly shorter on the impacted side (Table II), while the
crown of the canine was shown to be significantly taller (Table III).

Table II Comparison between crown lengths of lateral incisor and canine of two sides

Cases Control
Crown t p
(n = 45) (n = 45)
Lateral incisor
Min. – Max. 5.50 – 11.70 6.56 – 10.86
Mean ± SD. 8.88 ± 1.39 8.93 ± 1.13 0.453 0.653
Median 9.31 9.18
Canine
Min. – Max. 7.40 – 12.66 6.0 – 11.76
Mean ± SD. 9.86 ± 1.20 9.55 ± 1.33 2.110* 0.041*
Median 10.0 9.78
t: Paired t-test
p: p value for comparing between the studied periods
Table III Comparison between root lengths of lateral incisor and canine of two sides

Cases Control
Root t p
(n = 45) (n = 45)
2
Min. – Max. 7.27 – 15.22 10.21 – 16.0
Mean ± SD. 11.94 ± 2.08 12.82 ± 1.64 3.048* 0.004*
Median 12.31 13.10
3
Min. – Max. 10.83 – 18.70 11.70 – 18.78
Mean ± SD. 14.70 ± 1.84 15.08 ± 1.86 1.300 0.201
Median 14.57 15.18

t: Paired t-test
p: p value for comparing between the studied periods
*: Statistically significant at p ≤ 0.05

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Interpremolar width was significantly less on the case side than the control side while the intermolar
width has no statistically significant difference between two sides.Table IV

Table IV Comparison between the two sides according to maxillary transverse dimensions.

Cases Control
Arch dimensions t p
(n = 45) (n = 45)
Interpremolar
Min. – Max. 15.36 –30.93 15.55 –29.34
Mean ± SD. 22.78 ±4.38 23.37 ±3.88 2.085* 0.043*
Median 21.80 23.76
Intermolar
Min. – Max. 19.43 –75.91 21.09 –74.31

Mean ± SD. 29.32 ±8.71 29.36 ±8.27 0.143 0.887

Median 29.98 29.99

t: Paired t-test Z: Wilcoxon signed ranks test

p: p value for comparing between the studied periods
*: Statistically significant at p ≤ 0.05

Arch perimeter was found to be significantly smaller on the case side than the control side.
Angulation of the canines was found to be insignificantly more divergent on the control side than the
case side. The volume of the canine was found to be significantly larger on the case side than the control
side. (fig 10)

Figure 9 Comparison between the two studied periods according to Arch perimeter mm,
Angulation and Volume mm3

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Becker, Sharabi, & Chaushu, agreed with
Palatal canine displacement has been a
our results they stated that no difference
subject of orthodontic considerations since
between the size of teeth on affected and
early stages. Failure of canine to erupt into its
unaffected sides, in unilateral palatally
normal position has several reasons in our
displaced canines. 13
study we are concerned about the
morphological features of the canine and the Oliver et al disagreed with our results.
surrounding dentition so as to determine the They stated that the maxillary lateral incisor
common risk factors causing palatal adjacent to an impacted canine is generally
displacement of the canine. smaller than the contra- lateral incisor. This
contradiction may be due to ethnic origin as he
Several studies worked on the
they made their study on Caucasian population.
morphological etiological factors of canine 10
impaction(Abdel-Salam, El-Badrawy, &
Tawfik, 2012; Brenchley & Oliver, 1997; Kim, These results were in disagreement with
Hyun, & Jang, 2017; Oliver, Mannion, & those of Mossey, Campbell, & Luffingham
Robinson, 1989) most of them were focused on they concluded thatsubjects with narrower than
the size and shape of lateral incisor, only few average maxillary lateral incisor crowns are
studies related the whole maxillary dentition more at risk of palatal displacement of the
morphological features to the canine impaction maxillary canine.14
12
cone beam x-rays were used to evaluate root Difference in the crown/root ratio
lengths, shape and volume of canines. of the maxillary teeth between the
Our study was designed as a split mouth impaction and comparison sides
retrospective study on 45 cone beam x-rays. All the results showed no statistically
The impacted side served as case and the significant difference on crown/root ratio
normally erupting side as the control, data were between the impacted side and the normally
collected, compared and analyzed. erupting side except for the lateral incisor and
Difference in the mesiodistal canine which showed increased crown/root
width of the maxillary teeth between ratio.
the impaction and comparison sides Further analysis of the data for the lateral
When comparing the mesiodistal width of incisor and the canine were made showed
maxillary teeth it showed that there is no decreased root length of the lateral incisor and
statistically significant difference between the increased crown length of the canine on the
two sides. impacted side.
Our results came in line with those of Al- Our results came into agreement with
Nimri & Gharaibeh who stated that The those findings of Kim et al. in 2017 who stated
mesiodistal widths of the maxillary teeth were that the length and volume of the maxillary
not significantly different in the impaction and lateral incisor’s root were significantly smaller
comparison groups.12 on theimpaction side compared with the
normal eruption side, and the width and

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volume of the crown were significantly greater These results were similar to those from
on the impaction side compared with the McConnell et al16, who reprted that subjects
normal eruption side This indicates that there is with maxillary canine impactions had
a high correlation between maxillary canine transverse maxillary deficency exhibited in the
impaction and smaller lateral incisor root anterior portion of the dental arch. No
sizes.5 differences were detected between the groups’
intermolar widths.
This may lead to lack of canine root
guidance which leads to canine impaction. These results contradicted the findings of
Langberg & Peck who stated that arch width
Our results showed if the root of the
measurements of palataly displaced canines
lateral is less than ≤11.85 mm or the crown of the
subjects compared with a control group of age
canine more than >10 mm this may lead to
and gender matched orthodontic patients
occurrence of the anomaly.
indicate that there is no statistically significant
A systematic review done by Schroder et difference in the anterior and posterior
al., in 2018 stated that root resorption in maxillary arch width between palatlly
maxillary incisors was correlated with their displaced canines subjects and a sample of
contact with maxillary canines during eruption. control subjects. 17
Delayed eruption or treatment of impacted
This conflict may be due to difference in
canines may lead to resorption of the adjacent
study design, as they had two groups and
lateral and central incisors. All root levels and
compared iterpremolar and intermolar
surfaces of teeth associated with impacted
distances between impacted canine casts to
maxillary canines can be resorbed to different
control group with normally erupting pattern ,
levels of severity, but the apical one-third with
unlike our study as w had a split mouth design
slight resorption is the most common. 15
comparing two sides. Aslo it may be may be
This may conflict our results that root due to difference in ethnic origin as the sample
resorption of the lateral incisor was secondary was made on white people from northeastern
to palatal canine displacement not a United States while ours was made on egyptian
predisposing factor. population.
Difference between two sides Kim, Hyun, & Jang studied the
according to maxillary transverse relationship between the position of impacted
dimensions. maxillary canines and the morphology of the
Our results revealed statistically different maxilla 18. They supported the findings of
narrower arch dimension in the anterior McConnel et al. and concluded that the shape
(interpremolar) maxillary transverse dimension of the maxillary arch was narrower and longer
in the impacted side than the normally erupting in the palatally impacted canine group
side, while it showed no statistical difference in compared with the buccally impacted canine
the posterior (intermolar) maxillary transverse group, and the palatally impacted canine group
dimension between the impacted side and the had a deeper palatal vault than did the buccally
normally erupting side. impacted canine group.

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Difference between the two sides The average value of the angle between
according to arch perimeter. the tooth axis and the occlusal plane was lower
than the value of the contralateral well-aligned
Several authors have been commented on
canine.20
the existence of palatal canine impaction in
association with arch perimeter deficiency and Using three-dimensional CBCT imaging,
spaced dentition.(Jacoby, 2013;Stellzig, one study(Alqerban, et al, 2015) found that
Basdra, & Komposch, 1994) In our study arch angle of the canine to adjacent lateral incisor
perimeter was found to be significantly angle in the coronal view to be an excellent
narrower on the case side than the control side. predictor for canine impaction.
Our results showed that an interpremolar Angle between the long axis of canine and
distance of ≤20.55 would lead to occurrence of the dental midline there were no statistically
anomaly on this side. significant differences between impacted and
erupted canines.23
In contrast, Al-Nimri and Gharaibeh12
found no statistically significant difference in Difference between the two sides
the degree of crowding between that palatal according to volume of the canines.
canine impaction group and their matched In our study the volume of the canine
comparisons. However they stressed that these showed to be significantly larger on the case
results do not necessarily contradict the earlier side than the control side.
finding that the canines becomes palatally
impacted by crossing back to the palatal side if A cut off point of >539.25 mm3 of the
extra space is available in the maxilla 4, volume of the canine would lead to occurrence of
because crowding is a diagnosis related to the anomaly on this side.

inadequate space to accommodate the This was approved by Kim et al. as they
aggregated mesiodistal diameters of the crowns concluded thatthe width and volume of the
of the teeth. By contrast, the distance between crown were significantly greater on the
the roots of the same teeth may become impaction side compared with the normal
progressively larger, providing more space eruption side (P ¼ 0.020 and P , .0001,
mesiodistally in the root area, which is where respectively). This indicates that there is a high
the impacted canine is located. correlation between maxillary canine
5
Difference between the two sides impaction and greater crown sizes.
according to angulation of the Difference between the two sides
canines. according to presence of apical hook
In our study we measured the angulation of the canines.
of the canines, between the long axis of the On observation of the apical hook of the
crown and the long axis of the root was found canine (Vithanage et al, 2017) found that
to be insignificantly more divergent on the 36.4% of palatally impacted maxillary canines
control side than the case side. had a hook. In our study, 11.1% of palatally
impacted canines had a hook. 6.7% of the

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patients had apical hooks on the normally between the impacted side and the normally
erupting side and, 8% had apical hooks on both erupting side.
sides. 4.
25
Standerwick hypothesized that tooth root rch perimeter was found to be significantly
dilaceration and flexion resulted from tooth narrower on the case side than the control side.
root sheath displacement caused by gradients 5. The angulation of the canines, between
of plasticity in the alveolar bone.As a tooth is the long axis of the crown and the long axis of
erupting or experiences delayed eruption, other the root was found to be insignificantly more
relative dentoskeletal alterations are occurring, divergent on the control side than the case side.
such as mesial drift of the dentition and re-
modeling growth of the maxilla. (fig 11) 6. The volume of the canine showed to be
significantly larger on the case side than the
control side.
7. 11.1% of palatally impacted canines
had a hook. 6.7% of the patients had apical
hooks on the normally erupting side and, 8%
had apical hooks on both sides.
Thus a narrower interpremolar width,
increased canine volume, shorter root of lateral
incisor and increased length of canine crown
are contributing factors for impaction of the
Figure 11: Comparison between the sides canine.
according to hook. Refrences:
Conclusion: 1. Maverna, R. & G. Different diagnostic
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impaction and comparison groups. 2007;349–83.

2. No statistically significant difference on 2. Dachi SF, Howell F V. A survey of

crown/root ratio between the impacted side and 3,874 routine full-mouth radiographs. II. A
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maxillary canines. J Orthod. 2019; 24. Vithanage P, Shihanika K, Olive RJ,
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