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 Table of Contents  
ORIGINAL RESEARCH
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 70-73

Morphological Evaluation of Impacted Maxillary Canine and Adjacent Teeth Using Three-Dimensional Reconstructed CBCT Images: An Analytical Cross-Sectional Study


Department of Orthodontics and Dentofacial Orthopaedics, School of Dental Sciences, Sharda University, Greater Noida, UP, India

Date of Submission26-Mar-2022
Date of Decision09-May-2022
Date of Acceptance10-May-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Priya Kanak
Department of Orthodontics and Dentofacial Orthopaedics, School of Dental Sciences, Sharda University, Greater Noida, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/denthyp.denthyp_44_22

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  Abstract 


Introduction: The structural characteristics of unilaterally impacted maxillary canines and adjacent teeth were compared to the nonimpacted side. Three-dimensional (3D) cone-beam computed tomography (CBCT) was used to analyze and evaluate the various parameters. The aim of this study was a quantitative comparison of teeth adjacent to buccally and palatally impacted maxillary canines. Methods: CBCT records of 40 patients with unilateral impacted maxillary canine were allocated to this study. The morphological characteristics of teeth on the impaction and non-impaction sides of the same patient were examined. 3D reconstructed CBCT images were assessed using the OnDemand 3D program. Results: The dependent samples t test was used for data analysis with a level of statistical significance of 0.05. There was a significant increase in the size of the maxillary canine crown and a decrease in the maxillary lateral incisor root dimensions on the impacted side. No significant difference was observed in the morphology of the maxillary first premolar on either side. Conclusion: The impacted canine showed greater size compared to the eruption side. The decrease in root dimensions of the lateral incisor on the impacted side may indicate the possibility of root resorption.

Keywords: Impacted canine, root resorption, 3D reconstruction


How to cite this article:
Kanak P, Poonam A, Dinesh Kumar B, Richa M, Neelam S, Rajat G. Morphological Evaluation of Impacted Maxillary Canine and Adjacent Teeth Using Three-Dimensional Reconstructed CBCT Images: An Analytical Cross-Sectional Study. Dent Hypotheses 2022;13:70-3

How to cite this URL:
Kanak P, Poonam A, Dinesh Kumar B, Richa M, Neelam S, Rajat G. Morphological Evaluation of Impacted Maxillary Canine and Adjacent Teeth Using Three-Dimensional Reconstructed CBCT Images: An Analytical Cross-Sectional Study. Dent Hypotheses [serial online] 2022 [cited 2022 Aug 8];13:70-3. Available from: http://www.dentalhypotheses.com/text.asp?2022/13/2/70/350789




  Introduction Top


The maxillary canine is one of the most indispensable teeth in our alveolar arch due to its role in function and esthetics. It is also the second most frequently impacted tooth.[1] Canine impaction is seen predominantly in females and usually on the palatal aspect.[2] Unilateral canine impaction has been found to be more common than bilateral impactions.

While the exact etiology of canine impaction remains a topic of research, certain theories involving genetic and local factors have been considered. The guidance theory suggests that as the canine erupts close to the root of the maxillary lateral incisor, it guides the canine crown to erupt in its correct position. If the lateral incisor is missing or has a defective root, the canine will not be guided into the normal eruption.[3] Russell and McLeod observed that there are more incidences of canine impaction in cases with missing lateral incisors.[4]

The presence of impacted teeth runs the risk of severe complications, such as root resorption of adjacent teeth, misaligned teeth, and opening up of midline space.[5] According to Jacobs,[6] Shapira and Kuftinec,[7] and Liuk et al.,[8] palatally impacted canines apply pressure on the root of the lateral incisor causing palatal and distal tipping of its crown along with unwanted rotation.

The cone-beam computed tomography (CBCT) in the dental field has proven to be vitally important for diagnosis and treatment planning.[9] It is crucial in the case of impacted teeth to determine the exact position and spatial orientation of the tooth and adjacent structures in order to perform the necessary surgical exposure of the tooth and further traction into the dental arch.[10],[11],[12],[13]

The purpose of this study was to assess the structural characteristics of unilaterally impacted maxillary canines and adjacent teeth and their comparison to nonimpacted maxillary canines and adjacent teeth. CBCT data were used for reconstruction into three-dimensional (3D) volumetric imaging in order to analyze and evaluate the various parameters.

Aim of the study

The aim of this study was a quantitative comparison of the morphological characteristics of teeth adjacent to buccally and palatally impacted maxillary canines.

Objectives of the study
  • Morphological analysis of lateral incisors, impacted and nonimpacted maxillary canine, and first premolars using 3D reconstructed CBCT images
  • To make a comparative evaluation of the morphological characteristics of the assessed teeth



  Subjects and Methods Top


CBCT records of 40 patients were allocated to the present study. These were from patients who underwent orthodontic examinations at the Department of Orthodontics, School of Dental Sciences, Sharda University, Greater Noida and were suspected of unilateral impacted maxillary canine. The patients were then sent for CBCT to determine and localize the presence or absence of impacted maxillary canine. The files were in the format of Digital Imaging and Communications in Medicine (DICOM) and obtained from CBCT Carestream CS 9300 Select 3D Digital Imaging System (Carestream Dental LLC, Atlanta, GA, USA) at 70 to 84 kV. The OnDemand 3D program (Cybermed Inc., Seoul, Korea) was used to reconstruct the data from these DICOM images into 3D images for analysis. The vertical and horizontal planes in the natural head position were used as reference planes. Approval for this study was taken from Institutional Ethics Committee: SU/SMS&R/76-A/2018/143.

Sample size determination

To detect a difference in tooth dimensions on impacted and nonimpacted sides, with a 5% significance level and a power of 80%, a sample size of 34 patients was required in accordance with the study conducted by Kim et al.[14] Forty patient records were however included to identify outliers and minimize error.

Selection criteria

The inclusion criteria included CBCT records of patients with maxillary unilateral palatally or buccally impacted canine. The exclusion criteria for this study were CBCT records of patients with the following:
  • Adjacent teeth with resorbed roots
  • Missing adjacent teeth
  • Local factors like supernumerary teeth or retained deciduous teeth
  • Multiple impacted teeth


The morphological characteristics of the teeth on the impaction and the non-impaction side of the same patient were examined. Isolation of each tooth was done using the OnDemand 3D program followed by the required measurements.[15],[16],[28]

The following characteristics were measured in canines:
  1. Width of the crown taken from its widest mesiodistal portion in mm
  2. Anatomic height of the crown taken from the longest occluso-cervical distance in mm
  3. Volume of the crown in mm3[29]


In the case of lateral incisors and first premolars, the following characteristics were measured:
  1. Root length measured from the buccal Cemento-enamel junction (CEJ) to the root apex in mm
  2. Volume of the root in mm3


Statistical analysis

The data was analyzed using Statistical SPSS 25 (SPSS Inc., Chicago, IL, USA). Shapiro–Wilk test was used to check the normality of the data. The dependent samples t test was used for data analysis. The level of statistical significance was set at 0.05. The intra-observer reliability was analyzed for repeated measurements to calculate intraclass correlation coefficients (ICCs) with 95% confidence intervals.


  Results Top


[Figure 1] and [Figure 2] showed results of the comparison of the mesiodistal width, height, and volume of the maxillary canine crown, maxillary lateral incisor, and maxillary first premolar on the impacted and the nonimpacted side. The P value was found to be statistically significant for the mesiodistal width and volume of the maxillary canine crowns (P < 0.05). The ICCs were in the range of 0.75 to 0.9, showing good reliability.
Figure 1 Box and whisker plot showed results of the comparison of the maxillary canine crown mesiodistal width, height, and volume between the impacted and nonimpacted sides using dependent t test

Click here to view
Figure 2 Box and whisker plot showed results of the comparison of the root length and volume of maxillary lateral incisor and maxillary first premolar between the impacted and nonimpacted sides using dependent t test

Click here to view



  Discussion Top


In the present study, the position and characteristics of the maxillary canine, lateral incisor, and first premolar were assessed on both impacted and nonimpacted sides. Unlike older studies done using diagnostic casts, this study examines the root morphology of adjacent teeth and crown of canine using 3D reconstructed CBCT images.

A comparison of root resorption in adjacent teeth between impacted and nonimpacted sides was performed on the same subjects in order to achieve true pairing. This eliminated the need of having a control group of cases without impacted canines as it had the disadvantage of variation in genetic material.

The results showed a statistically significant increase in the dimensions of the impacted maxillary canine. This would make it necessary for the clinician to create more space than the dimensions of the erupted canine before orthodontic canine traction is attempted.[17]

The impaction of canines may lead to the ectopic eruption of adjacent teeth, arch collapse or reduced length, and even cysts or tumors.[18] A very deleterious and commonly observed effect of impacted canine is the root resorption of adjacent teeth. This can lead to mobility and subsequent tooth loss.[19]

The lateral incisors also showed a statistically significant decrease in the length and volume of root on the side of canine impaction. Ericson and Kurol[20] performed research to examine the resorption of lateral incisors adjacent to the ectopic eruption of maxillary canines. It was found that when the canine cusp was located mesial to the lateral incisor, the risk of root resorption increased three times.[21]

Kim et al. compared the root length of the lateral incisor in cases of impacted maxillary canine and noted that the affected side had a shorter root length compared to the contralateral side.[14] Becker et al. performed a similar study using conventional radiographs and Liuk et al. with 3D radiographs to conclude that the root length of lateral incisors adjacent to palatally displaced canines was approximately 2.1 mm shorter than that on the contralateral side.[8],[14],[22],[23],[24],[25]

No statistically significant differences were observed in the morphologic characteristics of the maxillary first premolar between the impacted and nonimpacted groups. The maxillary canine eruption path did not have any impact on the volume or length of the maxillary first premolar crown. Similar results were observed by Cooke and Nute[26] in 2005 and Cernochova et al. in 2011.[27]

Previous studies by Ericson and Kurol in 2000 and Alqerban et al. in 2011 prove that the quality of information that can be obtained from 3D reconstructed CBCT data is much superior to that using the 2D radiographic approach.[20],[28],[29] This makes the 3D analysis using CBCT data the preferred diagnostic aid while treatment planning.

Limitations of the study are that it is difficult to demarcate the limits of enamel, cementum, and alveolar bone that may have caused some errors in segmentation. This study does not consider any correlation between the angulation of impacted teeth and the extent of root resorption.


  Conclusion Top


The conclusions to be drawn from the study are as follows:
  • The root resorption of the maxillary lateral incisor was significantly increased on the impacted canine side.
  • The root resorption of maxillary first premolar, though present, was not significant on the impacted side.
  • The increase in root resorption of maxillary lateral incisor on the side of nonimpacted canine was not significant.
  • The root resorption of maxillary first premolar was not found to be significant on the nonimpacted side.
  • The canine crown size is relatively more on the impacted side.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Oberoi S, Knueppel S, Francisso S. Three-dimensional assessment of impacted canines and root resorption using cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:260–62.  Back to cited text no. 1
    
2.
Becker A, Smith P, Behar R. The incidence of anomalous maxillary lateral incisors in relation to palatally-displaced cuspids. Angle Orthod 1981;51:24–9.  Back to cited text no. 2
    
3.
Chaushu S, Kaczor-Urbanowicz K, Zadurska M et al. Predisposing factors for severe incisor root resorption associated with impacted maxillary canines. Am J Orthod Dentofac Orthop 2015;147:52–60.  Back to cited text no. 3
    
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Russell KA, McLeod CE. Canine eruption in patients with complete cleft lip and palate. Cleft Palate Craniofac J 2008;45:73–80.  Back to cited text no. 4
    
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Postlethwaite KM. Resorption of premolar roots by ectopic canines. Br Dent J 1989;9:23–4.  Back to cited text no. 5
    
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Jacobs SG. Reducing the incidence of unerupted palatally displaced canines by extraction of deciduous canines. The history and application of this procedure with some case reports. Aust Dent J 1998;43:20–7.  Back to cited text no. 6
    
7.
Shapira Y, Kuftinec MM. Early diagnosis and interception of potential maxillary canine impaction. J Am Dent Assoc 1998;129:1450–4.  Back to cited text no. 7
    
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Liuk W, Olive RJ, Griffin M, Monsour P. Maxillary lateral incisor morphology and palatally displaced canines: a case-controlled cone-beam volumetric tomography study. Am J Orthod Dentofacial Orthop 2013;143:522–26.  Back to cited text no. 8
    
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Alqerban A, Jacobs R, Souza PC, Willems G. In-vitro comparison of 2 cone-beam computed tomography systems and panoramic imaging for detecting simulated canine impaction-induced external root resorption in maxillary lateral incisors. Am J Orthod Dentofacial Orthop 2009;136:764–75.  Back to cited text no. 9
    
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Walker L, Enciso R, Mah J. Three-dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2005;128:418–23.  Back to cited text no. 10
    
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Hofmann E, Medelnik J, Keller T et al. Measuring mesiodistal width of impacted maxillary canines. J Orofac Orthop 2011;72:33– 44.  Back to cited text no. 11
    
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Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two versus three-dimensional imaging in subjects with unerupted maxillary canines. Eur J Orthod 2010;33:344–9.  Back to cited text no. 12
    
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Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ, Huang JC. Comparative analysis of traditional radiographs and cone-beam computed tomography volumetric images in the diagnosis and treatment planning of maxillary impacted canines. Am J Orthod Dentofacial Orthop 2010;137:590–7.  Back to cited text no. 13
    
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Kim Y, Hyun HK, Jang KT. The position of maxillary canine impactions and the influenced factors to adjacent root resorption in the Korean population. Eur J Orthod 2012;34:302–6.  Back to cited text no. 14
    
15.
Kanak P. Fig. 1. The tooth was isolated and selected using the object mask tool.jpg. figshare. 2022. https://figshare.com/articles/figure/Fig_1_The_tooth_was_isolated_and_selected_using_the_object_mask_ tool_jpg/19562881  Back to cited text no. 15
    
16.
Kanak P. Fig. 2. Volume of the crown was measured.jpg. figshare. 2022. https://figshare.com/articles/figure/Fig_2_Volume_of_the_crown_ was_measured_jpg/19562878  Back to cited text no. 16
    
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Jacoby H. The etiology of maxillary canine impaction. Am J Orthod 1983;84:125–32.  Back to cited text no. 17
    
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Arens DE. An alternative treatment for the severely resorped maxillary lateral incisor: a sequelae of ectopic eruption. J Endod 1995;21:95–100.  Back to cited text no. 19
    
20.
Ericson S, Kurol J. Incisor resorptions due to ectopic maxillary canines imaged by computerized tomography: a comparative study in extracted teeth. Angle Orthod 2000;70:276–83.  Back to cited text no. 20
    
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Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74.  Back to cited text no. 21
    
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Kamiloglu B, Kelahmet U. Prevalence of impacted and transmigrated canine teeth in a Cypriote orthodontic population in the Northern Cyprus area. BMC Res Notes 2014;7:34–6.  Back to cited text no. 23
    
24.
Brin I, Becker A, Zilberman Y. Resorbed lateral incisors adjacent to impacted canines have normal crown size. Am J Orthod Dentofac Orthop 1993;104:60–6.  Back to cited text no. 24
    
25.
Becker A, Chaushu S. Long-term follow-up of severely resorbed maxillary incisors after resolution of an etiologically associated impacted canine. Am J Orthod Dentofac Orthop 2005;127:650–4.  Back to cited text no. 25
    
26.
Cooke ME, Nute SJ. Maxillary premolar resorption by canines: three case reports. Int J Paed Dent 2005;15:210–12.  Back to cited text no. 26
    
27.
Cernochova P, Krupa P, Izakovicova-Holla L. Root resorption associated with ectopically erupting maxillary permanent canines: a computed tomography study. Eur J Orthod 2011;33:483–91.  Back to cited text no. 27
    
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Alqerban A, Jacobs R, Fieuws S, Willems G. Comparison of two cone beam computed tomographic systems versus panoramic imaging for localisation of impacted maxillary canines and detection of root resorption. Eur J Orthod 2011;33:93–102.  Back to cited text no. 28
    
29.
Ardakani MP, Nabavizadeh A, Iranmanesh F, Hosseini J, Nakhaei M. Relationship of Angulation of Maxillary Impacted Canines with Maxillary Lateral Incisor Root Resorption. Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2021, 21; e0164.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2]



 

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