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28 May 2024: Clinical Research  

Maxillary Canine Impaction: Assessing the Influence of Maxillary Anatomy Using Cone Beam Computed Tomography

Mujgan Firincioglulari ORCID logo1ABEF*, Doga Kurt2BCDE, Sevgi Koral2ABEF, Kaan Orhan ORCID logo34ABDE

DOI: 10.12659/MSM.944306

Med Sci Monit 2024; 30:e944306

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Abstract

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BACKGROUND: The purpose of this study was to evaluate the anatomical characteristics of patients with unilateral impacted canine teeth compared to a control group. Cone beam computed tomography (CBCT) records were retrospectively analyzed.

MATERIAL AND METHODS: CBCT records of 64 patients with unilateral impacted canine teeth (57.8% female and 42.2% male) and 64 controls (59.4% female and 40.6% male) were retrospectively analyzed. On the CBCT images, intermolar width, arch length, arch perimeter, palatal width in the molar region at cementoenamel junction, palatal width in the molar region at the crest, palatal width in the molar region measured from mid-root level, nasal cavity width, and palatal depth were evaluated.

RESULTS: In the palatal width measurement from the mid-root variable, the measurement of labially positioned canines was significantly lower than the control group (P<0.05). In terms of intermolar width, the labial positioned impacted canines’ values were lower than in the control group. There was a significant difference in terms of the perimeter variable and both palatinally and labially positioned impacted canines were significantly lower than in the control group (P<0.05). All parameters were compared according to sex, and measurements of male patients were significantly higher than in female patients (P<0.05).

CONCLUSIONS: A labially impacted canine was strongly linked to a decrease in mid-root palatal and intermolar widths. Additionally, impacted canines positioned both palatally and labially were found to result in a reduced arch perimeter. Moreover, male patients with impacted canines exhibited notably greater anatomical measurements compared to female patients.

Keywords: Anatomy, Diagnostic Imaging, Tooth, Impacted

Introduction

Teeth whose root development has been completed and whose eruption is prevented for some reason are defined as impacted teeth [1]. Tooth impaction is a common dental irregularity frequently seen in orthodontic practice, posing a remarkable challenge in orthodontic treatment. After the third molars, maxillary canine impaction is the second most frequent form of tooth impaction, with an incidence ranging from 0.9% to 2.2% [2].

Impaction of maxillary canines is commonly seen unilaterally and palatally and there is a 3: 1 ratio for palatal-to-buccal impaction, and the incidence is twice as high in females as in males [3,4]. According to McConnell et al [5] and Sambataro et al [6], 8% of impacted canine cases involve bilateral impaction. A prevalence ratio of 5: 1 for unilateral impaction-to-bilateral impaction was also reported by Kuftinec et al [7].

Maxillary canine impaction can form a barrier to achieving favorable facial and smile aesthetics, as these teeth have a significant role in maintaining pleasing proportions [8]. The optimal strategy for addressing impacted maxillary canines involves early detection and intervention to prevent potential impaction. Nonetheless, if preventive measures are not taken, orthodontic treatment followed by surgical exposure of the canine to facilitate its alignment with adjacent teeth is recommended by clinicians [9]. Orthodontic traction of maxillary impacted canines is a multidisciplinary treatment that requires a long treatment time. Factors such as the position of the impacted maxillary canine, the degree of impaction, and the patient’s age are considered while determining the orthodontic treatment options [10]. If not treated promptly, impacted maxillary canines can cause problems in the mouth, such as root resorption of neighboring incisors or those near the area of eruption. Hence, it is crucial to receive early and appropriate treatment from an orthodontist, involving the use of traction on the impacted canine, to prevent adverse outcomes [11].

Numerous factors have been proposed as potential causes for impaction of maxillary canines, including genetic factors [12], variations in maxillary arch length [13], an extended path of maxillary canine eruption [14], morphology of the adjacent lateral incisor [15], incomplete resorption of the primary canine root, and other dental anomalies [13].

The positioning of canines in the labiopalatal dimension was specified as either labial, mid-alveolus, or palatal, determined by the relative placement of the canine crown to adjacent teeth [16].

Cone beam computed tomography (CBCT), alternatively referred to as digital volume tomography, involves presenting image data digitally and, most importantly, representing anatomy in 3 dimensions (3D). The initiation of CBCT dates back to 1995, marked by the introduction of the inaugural dental CBCT model, the NewTom DVT 9000, by Italian developers Attilio Tacconi and Piero Mozzo [17]. CBCT is preferred over traditional computed tomography due to its higher image quality, reduced radiation dosage, and cost-effectiveness. These qualities build up the accessibility of three-dimensional assessment for craniofacial structures [18,19] and enable analyzing high-quality diagnostic 3D images at any dimension [20].

Recent research has indicated variations in the prevalence of maxillary impacted canines across diverse populations. Therefore, this retrospective study aimed to compare the CBCT parameters of 64 patients with unilateral impacted maxillary canine teeth with 64 controls in the North Cyprus population.

Material and Methods

ETHICS APPROVAL AND SAMPLE COLLECTION:

The study was approved by the Ethical Review Board (EKK23-24/003/06) of Cyprus International University. The 1964 Helsinki Declaration, its later revisions, or equivalent ethical standards, as well as the institutional and/or national research committee’s ethical standards, covered all procedures carried out in studies involving human participants.

The data collected for this research was obtained from a private dental imaging center in Nicosia. Informed consent was obtained from all individual participants included in the study. Around 1000 CBCT images were analyzed and we selected 64 that had a unilateral impacted canine. In the study group, 37 of these patients were female (57.8%) and 27 of them were male (42.2%). The average age for the study group was 17.4. The control group consisted of 36 female patients (59.4%) and 28 male patients (40.6%), with an average age of 22.9 years.

SAMPLE SIZE ESTIMATION:

According to the power analysis for the power of 80%, each group (patients with impacted canine and control group) should consist of 45 samples. This study included 64 patients with unilateral impacted canine and 64 patients without impacted canine as the control group.

INCLUSION CRITERIA:

Patient inclusion criteria for the study group were: (1) no previous orthodontic treatment, (2) absence of impacted teeth other than maxillary canine or third molars, (3) no developmental anomalies, (4) no intensive crowns or large restorations, (5) patients with high-quality CBCT images, and (6) patients without systemic diseases. For the control group, patients with fully erupted maxillary permanent teeth were selected.

EXCLUSION CRITERIA:

Patient exclusion criteria for the study group were: (1) previous orthodontic treatment, (2) existence of odontoma or supernumerary teeth, (3) existence of any congenital dentofacial anomaly (cleft lip or palate), (4) existence of multiple impacted teeth, and (5) congenitally missing teeth.

CBCT ANALYSIS:

CBCT radiographs are obtained by using a Newtom GO 3D/2D (Quantitive Radiology s.r.l., Verona, Italy). Scanning parameters were 90 kvP,24 s,4 mA, voxel size 0.3 mm, and field of view 10x10 cm. The measurements are done by using the machine’s computer software (NNT viewer 4.2, QE Verona, Italy) and were recorded in millimeters (mm). Parameters were analyzed in the axial, sagittal, and coronal planes. CBCT records were analyzed twice by 2 observers (D.K. and M.F.) at 1-week intervals to look for any inter- and intra-observer variability.

MEASUREMENTS:

The following measurements were performed on the CBCT images to analyze the effect of a unilateral maxillary canine on the maxilla: (1) intermolar width, (2) arch length, (3) arch perimeter, (4) palatal width in molar region at cementoenamel junction, (5) palatal width in molar region at crest, (6) palatal width in molar region measured from mid-root level, (7) nasal cavity width, and (8) palatal depth.

Intermolar width was measured with a line between the mesiobuccal cusps of the right and left first molars from an axial view. For the arch length, a perpendicular line was drawn from the incisor edge of the upper central incisors to the line used for measuring intermolar width. If there was a difficulty in locating the incisor edge of the corresponding teeth, the most labial side of the tooth was used for measurement.

For calculating the arch perimeter, tooth groups were categorized and measured separately. Starting from the mesiobuccal cusp of the first molar to the distal side of the canine, the canine distance was measured separately from the mesial side of the canine to the mesial side of the central incisor. The same procedure was continued on the other half of the arch, and then these values were added together to calculate the arch perimeter (Figure 1).

The assessment of palatal width was conducted using the coronal section of the CBCT. This measurement was divided into 3 segments to enhance clarity in observing the effects. Specifically, measurements involved drawing a line between the left and right maxillary first molars, considering the cementoenamel junction, crest, and mid-root of the molars. Each of these 3 segments was analyzed independently. Palatal depth was measured with a line drawn from the deepest point on the palatal vault to the alveolar crest line used to measure the palatal width (Figure 2).

Figure 3 shows the measurement of nasal cavity width that was determined from the coronal section of the CBCT, focusing on the clear visibility of the first maxillary molars. The measurement involved assessing the width of the cavity at its broadest point.

STATISTICAL ANALYSIS:

Measures of intra- and inter-examiner validation were carried out. For repeat measures, the Wilcoxon matched-pairs signed-rank test was used to assess intra-observer reliability. The intraclass correlation coefficient and the coefficient of variation (CV ¼ (standard deviation/mean) 100%) showed interobserver dependability. The intraclass correlation coefficient has values between 0 and 1. Good dependability is expressed by intraclass correlation coefficient values more than 0.75, and reproducibility is represented by the precision error’s low coefficient of variation and low coefficient of variation.

The data obtained from the measurements were transferred to the SPSS 24 program via Excel. Within the scope of this study, both descriptive statistics (frequency, percentage, cross-tabulation) and hypothesis tests were used. The results of the descriptive statistics analysis are shown in Table 1.

To select the appropriate hypothesis tests for the analysis of hypothesis tests, the values obtained from the measurements were analyzed using the homogeneity tests Kolmogorov-Smirnov and Shapiro-Wilk tests. Since no significant difference was observed in the results of the homogeneity tests, the 2nd and 3rd sub-problems of the study were analyzed using parametric statistics since the data met the assumption of normal distribution in this study.

Independent sample t test was used to compare the parameter measurements between 2 groups such as side and sex. In the comparison according to position, a one-way analysis of variance (one-way ANOVA) was used since the number of groups was over 2. The results of Levene’s test were taken into consideration before making multiple comparisons between the groups between the significant differences of the ANOVA, and since the Levene’s test results met the homogeneity assumption and the number of observations between groups was not equal, multiple comparisons between groups were analyzed with the post hoc least significant difference test. For the hypothesis tests conducted within the scope of this study, P<0.05 was accepted as significant.

Results

DISTRIBUTION OF THE IMPACTED CANINES:

In the control group, 49.3% of the patients were female, 37% had impacted canines on the right side, 13.7% had impacted canines on the left side, 50.9% of the patients were male, 27.3% had impacted canines on the right side, 21.8% had impacted canines on the left side, and there was no significant difference between these distributions according to the chi-square test (P>0.05) (Table 1A).

EVALUATION OF THE POSITION OF IMPACTED CANINE:

When analyzed in terms of position, mid-alveolus was seen in 15.1% of women and 16.4% of men. Palatinal position was seen in 27.4% of women and 25.5% of men. The labial position was seen in 8.2% of women and 7.3% of men. There was no significant difference between the distributions in terms of position according to the chi-square test (P>0.05) (Table 1A).

EVALUATION OF MORPHOMETRIC PARAMETERS:

Palatal width measurements from the cementoenamel junction, alveolar crest, and midfoot of the maxillary first molar parameters were compared according to sex, and the measurements of male patients were found to be significantly higher than those of females (P<0.05). Intermolar width, palatal depth, arc length, arch perimeter, and nasal cavity width values of male patients were significantly higher than those of females (P<0.05) (Table 1B).

Table 2 shows the result of the measurements of palatal width measured from the cementoenamel junction, alveolar crest, palatal depth, arch length, and nasal width, showing that there was no significant difference between the groups (P>0.05). There was a significant difference in the palatal width measured from the mid-root variable, and the labially positioned canines were significantly smaller than in the control group (P<0.05).

There was no difference in the intermolar width variable according to the P value, but when the post hoc results and the arithmetic averages between the groups were examined, the labial positioned impacted canines’ values were lower than in the control group.

There was a significant difference in terms of the perimeter variable and according to the post hoc results, and both palatinally and labially positioned impacted canines were significantly lower than in the control group (P<0.05).

EVALUATION OF PARAMETERS BY SEX:

Table 3 illustrates the comparison of measurements by sex. Results showed that there was no significant difference in palatal width measurement from cementoenamel junction, alveolar crest, mid-root, palatal depth, arch length, and nasal cavity width variables in women (P>0.05). According to the post hoc test results, there was a significant difference in terms of intermolar width variable in women, and the labial group measurement was lower than in the control group and palatinal group measurements (P<0.05). There were significant differences in the measurements between the groups in terms of the arc perimeter variable in women, and the measurements of the labial and palatinal groups were significantly lower than in the control group (P<0.05).

In males, while there were no significant differences in any variables according to P value, according to post hoc test results, in the palatal width from the mid-root variable, the measurements in the labial group were lower than in the control group, while in the perimeter variable, the measurement in the palatinal group was lower than in the control group (P<0.05). Table 4 shows that none of the parameters showed any difference according to the location of the impacted canine.

Discussion

Causes of impaction of maxillary canine have been searched in the literature by many studies [25–30]. As there are different etiological causes of impacted canines, maxillofacial and dentoalveolar structures are associated with impaction in some research [21]. This study was carried out on CBCT images rather than two-dimensional images obtained by conventional methods.

Cone beam computed tomography is an essential 3D radiographic diagnostic tool, focusing on a specific area of interest with high-definition images [18,22]. It also is the most efficient imaging method to diagnose the impaction of canines in orthodontic practice [22]. In this study, correlations between maxillary impacted canines and morphology of the maxilla such as palatal width, intermolar width, palatal depth, arch length, arch perimeter, and nasal width were determined by analyzing 3D images derived from CBCT.

We found no significant association between the position of the maxillary impacted canine and sex or impaction side. Impacted maxillary canines were more common in females.

Kucukkaraca et al [23] found impacted maxillary canines were more common in females than in males, which agrees with our results.

According to Harzer et al [24], the left side of the maxilla has a higher incidence of impacted canines, but it was also reported that impaction of maxillary canines was more common on the right side [25,26]. However, our results showed no significant difference between the impaction sides of maxillary canines. This might be attributed to differences in the ethnicity of subjects, sample sizes, distributions, or measurement tools.

Genc et al [27] found no significant difference between the distributions in terms of the position of the maxillary impacted canine, which is similar to our results in terms of the position of the impacted canine.

Furthermore, for the morphometric parameters, all variables were higher in male patients than in females. These present findings reveal that there is more transverse growth of the maxilla and maxillary arch in male patients with impacted canines.

For both sexes, arch perimeters with palatal and labial positioned impacted canines were lower than in the control group. In male patients, the arch perimeter was lower only in the palatal positioned canine impaction. A difference was observed in the intermolar width among the female patients, while the male patients in the labial group had less palatal width measured from the mid-root.

Measurements of palatal width at the mid-root of labially positioned canines were lower than the control group. This result shows that the eruption of labially positioned maxillary canines can play an important role in development of the palatal maxilla. Transverse growth of the maxilla was completed before the eruption of canines [28,29]; therefore, deficiency of the maxilla in the transverse direction can lead to impaction of canines. Furthermore, intermolar width with labial positioned impacted canine was found to be lower than in the control group. Moreover, there was no association between nasal cavity width and maxillary canine impaction.

The results of palatal width and intermolar width in terms of sex in our study are similar to the literature [21,30,31,32].

In terms of arch perimeter, the results of our study are similar to the outcomes of other research in the literature [31,33,34]. Contrary to these outcomes, Oleo et al [35] reported that 80% of patients with palatal impacted canine had an adequate arch perimeter. In a different study, it was reported that ethnicity could affect the dental arches, which are more extended in African people than in Whites [36].

Contrary to our results, Refaat et al [33] stated that the intermolar width and arch length measurements were higher in males with palatal impaction, whereas the Cucaracha palatal depth, maxillary width, and nasal cavity width values were higher than those in female patients in the buccal impaction group.

On the other hand, Shahin et al [22] reported that arch length and palatal depth were significantly smaller in patients with impacted canines than in the control group, unlike our results. It was reported that the arch length in the labial positioned maxillary impacted canine group was a statistically significant parameter.

Similar to our result in terms of palatal width, McConnell et al [5] found an association between the transverse deficiency of the maxilla and palatal positioned impacted canines. However, some studies in the literature did not find any significant differences between the measurements of maxillary width and maxillary impacted canines [37–40]. This controversy between the studies about maxillary transverse dimension and impacted canine might be attributed to the variation of measurement tools, sample size, and ethnicity of subjects.

Similar to our results, a CBCT study by Yan et al [41] found smaller maxillary width in subjects with buccal-positioned impacted canines. Arboleda et al [42] reported that transverse dimensions of the first premolar and first molar were smaller in impacted canine samples than in the control group without impaction. These results indicate that smaller maxillary transverse dimensions are associated with a high impaction risk of maxillary canines.

The literature and our results suggest that early diagnosis of maxillary transverse deficiency can prevent impaction of maxillary canines with interceptive treatments.

Kim et al [43] and Saiar et al [37] did not find any significant difference in terms of nasal cavity width between the impaction and control group, in agreement with our results, but Alshehri et al [44] found that the nasal cavity was wider in patients with unilateral canine impaction. Conflicting results on the relationship between nasal cavity width and maxillary impacted canines can be attributed to the use of different materials, tools, and study designs.

The limitations of this current study include the small sample size and retrospective single-center design including only 1 ethnic population. Despite the limited sample size, this study enhances the current evidence concerning the correlation between impacted maxillary canines and maxillary morphology. Further investigation is necessary to assess angular and linear measurements on CBCT images within a broader population sample. Hence, future research should be carried out on a multicenter scale, aiming to compare these parameters across diverse racial and ethnic groups.

Conclusions

Labially impacted canines were strongly associated with smaller mid-root palatal width and intermolar width, and palatinally and labially positioned impacted canines had smaller arc perimeters. Male patients with impacted canines had significantly greater anatomical measurements than female patients.

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