ORIGINAL ARTICLE

Influence of impacted maxillary canine

orthodontic traction complexity on root
resorption of incisors: A retrospective
longitudinal study
Luis Ernesto Arriola-Guille
n,a Gustavo Armando Ru
ız-Mora,b Yalil Augusto Rodr
ıguez-Ca
rdenas,c
Aron Aliaga-Del Castillo,d Mariana Boessio-Vizzotto,e and Heraldo Luis Dias-Da Silveirae
Lima, Per

u, Bogot
a, Colombia, Bauru, S~ao Paulo, and Porto Alegre, Rio Grande do Sul, Brazil

Introduction: The orthodontic traction of impacted canines is a procedure of variable complexity. The objective
of this study was to determine the influence of this complexity on the root resorption (RR) of adjacent incisors,
using cone-beam computed tomography. Methods: This longitudinal retrospective study included 45 patients
(19 female, 11 male; ages, 18.16 6 7.3 years) with maxillary impacted canines, classified into 2 groups accord-
ing to the level of orthodontic traction complexity: low complexity group (n 5 20) and high complexity group
(n 5 25). The amounts of RR of 45 maxillary central and 45 lateral incisors were evaluated before and after treat-
ment. Complexity was defined considering impaction sector, eruption inclination angle, and canine position
(palatal, buccal, or bicortical). Three orthodontists measured RR in each maxillary incisor. Independent t tests
or Mann-Whitney U tests were used to compare resorption between groups depending on the normality of
the data. A multiple linear regression was calculated to evaluate the influence of all variables on RR
(a 5 0.05). Results: RR of maxillary incisors in the sagittal, coronal, and axial sections showed no significant
differences between groups (P . 0.05). Independently of the groups, RR ranged approximately from 1 to
1.5 mm and from 3 to 4 mm2. RR was less than 2 mm2 in the axial sections. Multiple linear regression indicated
no significant influence of orthodontic treatment complexity on RR. Male patients had more RR, specifically in the
maxillary central incisors than female patients (P \ 0.05). Conclusions: The complexity of orthodontic traction
of impacted maxillary canines is not a risk factor for greater RR of maxillary incisors close to the impaction area.
(Am J Orthod Dentofacial Orthop 2019;155:28-39)

O
ne undesired side effect after orthodontic treat- approximately 60% of treated patients but usually is
ment is root resorption (RR), mainly of the maxil- less than 1 mm.4 However, in some patients, RR may
lary incisors.1-3 RR has been reported in be severe (more than 4 mm) and could be related to
various factors, including root shape and length, long
a
Divisions of Orthodontics and Oral and Maxillofacial Radiology, School of orthodontic treatment, or heavy orthodontic forces.5
Dentistry, Universidad Cient
ıfica del Sur, Lima, Per
u. Lateral incisors are usually the most exposed.1,2 The
b
Division of Oral and Maxillofacial Radiology, School of Dentistry, Universidad
Cient
ıfica del Sur, Lima, Per

u; Division of Orthodontics, Faculty of Dentistry, Univer- orthodontic treatment of impacted canines requires
sidad Nacional de Colombia, Bogot
a, Colombia; Division of Oral and Maxillofacial special biomechanics,6 which include forces with
Radiology, Faculty of Dentistry, Universidad Nacional de Colombia, Bogotá, Colombia. different traction vectors supported on the neighboring
c
Division of Oral and Maxillofacial Radiology, School of Dentistry, Universidad Cient
ıf-
ica del Sur, Lima, Per
u. teeth using large-caliber arches to prevent side ef-
d
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo, Bauru, fects.7-10 This situation could increase the risk of RR
S~ao Paulo, Brazil. compared with a conventional orthodontic treatment
e
Division of Oral Radiology, Faculty of Dentistry, Federal University of Rio Grande do
Sul, Porto Alegre, Rio Grande do Sul, Brazil. approach.11
All authors have completed and submitted the ICMJE Form for Disclosure of Po- The reported prevalences of impacted maxillary
tential Conflicts of Interest, and none were reported. canines range from 0.92% to 6.04%12-14; this is
Address correspondence to: Luis Ernesto Arriola-Guill
en, Calle Los Girasoles
#194, Dpto. #302, Urb. Residencial Los Ingenieros de Valle Hermoso, Santiago considered a clinical challenge for orthodontists.
de Surco, Lima, Per
u; e-mail, luchoarriola@gmail.com. The treatment should try to maintain the unerupted
Submitted, December 2017; revised and accepted, February 2018. teeth to allow the development of the canine
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved. eminence, which is important for facial esthetics, and
https://doi.org/10.1016/j.ajodo.2018.02.011 to establish a canine guide that leads to a functional
28
Arriola-Guill
en et al 29

occlusion.15,16 The place of impaction is considered a MATERIAL AND METHODS

risk factor for RR, mainly the maxillary incisors. This retrospective longitudinal study was approved
Bicortically impacted canines in the middle of the 2 by the ethics and research committee of the Universi-
cortical bones could generate greater RR of the incisors dad Cient
ıfica del Sur in Lima, Peru (number 00008).
as a result of their eruption.17,18 Likewise, this The sample included 45 patients (11 male; 19 female;
condition could be a greater risk for resorption after age, 18.2 6 7.3 years) with maxillary impacted canines
traction. treated in a private orthodontic clinic (G.A.R.M.).
The location of impacted canines (palatal, buccal, or Two groups were established according to the level
bicortical) and the distance to the roots of the maxillary of orthodontic traction treatment complexity: low
incisors increase the risk of RR by direct contact with complexity group (n 5 20) and high complexity group
them during traction.17,19 To quantify the severity of (n 5 25). In both groups, the RR of the 45 maxillary
canine impaction, several classifications have been central and 45 maxillary lateral incisors adjacent to
made, allowing the orthodontist to estimate how the impacted canines were evaluated before and after
complex the treatment of a specific canine impaction traction (90 incisors) using cone-beam computed to-
could be.20-23 mography (CBCT) images. The minimum sample size
Any orthodontic treatment including canine disim- required was 20 impacted canines per group, deter-
pactation is considered complex.24,25 However, this mined by a formula to compare 2 means, with a 95%
complexity varies depending on location, sector, and confidence level and 80% test power, when the average
angle of impaction. Impacted canines closer to the difference of RR between groups was 0.5 mm (data
midline have greater complications during treatment. from a previous pilot test), and with a standard devia-
If an impacted canine crosses the midline toward the tion of 0.64 mm.
opposite side, the difficulty of the treatment will be The sectors of impaction according to the classifica-
high.26 The sectors of impaction 4 and 5 (close to the tion of Ericson and Kurol23,28 are presented in Table I.
midline) according to the classification proposed by Eric- The inclusion criteria were male or female patient with
son and Kurol23 are the most complex to treat because at least 1 impacted canine, with complete records
they require special biomechanics for orthodontic trac- including clinical histories, study models, extraoral and
tion. Likewise, the impacting angle clearly compromises intraoral photographs, panoramic and lateral head films,
the prognosis of the treatment; horizontally impacted and CBCT images before treatment and after canine
canines are more challenging for orthodontists than traction.
vertically impacted canines, which have the best Patients with periapical lesions circumscribed to the
prognosis. maxillary incisors before orthodontic treatment, with
It has been reported that there are no significant brackets or maxillary surgeries before the study, and
differences in RR after orthodontic traction in patients with agenesis of a maxillary tooth were excluded.
with unilateral vs bilateral impacted canines.27 Howev- The demographic and occlusal characteristics of the
er, bilateral impaction does not necessarily demand a sample are described in Table II.
complex treatment because it could involve 2 vertically The low complexity group included patients with
impacted canines or could be located between a lateral impacted maxillary canines in impaction sectors 1, 2,
incisor and a first premolar, with a good prognosis. or 3 according to the classification of Ericson and
Otherwise, a unilateral impaction is not always simpli- Kurol23,28 (Table I, Fig 1). In the case of sector 3, the a
fied treatment. If it is close to the midline or horizon- angle (angle between the interincisor midline and the
tal, the treatment may be more complex. This is why it long axis of the impacted canine) was 40 or less.
was considered important to demonstrate whether a Buccally or palatally maxillary impacted canines were
complex canine impaction treatment has a greater included.23 RR before orthodontic treatment was
risk for RR of the incisors adjacent to the canine measured (Tables III and IV).
impaction. The purpose of this study was to determine The high complexity group included patients with
the influence of orthodontic traction complexity of impacted maxillary canines in impaction sectors 3, 4,
impacted maxillary canines on the RR of adjacent or 5 according to the classification of Ericson and
incisors. Kurol.23,28 In the case of sector 3, the angle a was
The null hypothesis was that there is no significant greater than 40 . Buccally, palatally, and bicortically
difference in the amount and area of RR of the maxillary maxillary impacted canines (at the level of the
incisors after orthodontic traction of impacted canines occlusion line or exactly in the middle of the 2 cortical
with different levels of complexity. bones) were included (Tables III and IV).17,18

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30 Arriola-Guill
en et al

Table I. Classification of impacted canines of Ericson

and Kurol28
Sector Definition
1 The cusp tip of the canine is between the mesial aspect of
the first premolar and the distal aspect of the lateral
incisor
2 The cusp tip of the canine is between the distal aspect of
the lateral incisor and the long axis of the lateral incisor
3 The cusp tip of the canine is between the long axis of the
lateral incisor and the mesial aspect of the lateral
incisor
4 The cusp tip of the canine is between the mesial aspect of
the lateral incisor and the long axis of the central
incisor
5 The cusp tip of the canine is between the long axis of the
central incisor and the interincisor median line

Fig 1. Sectors of canine impaction, based on the study of

Ericson and Kurol.28
Table II. Initial characteristics of the sample
Variable Condition Total
Table III. Characteristics of the impacted canines ac-
Sex Male 11
Female 19 cording to orthodontic traction complexity
Angle malocclusion Class I 20
Low High
Class II Division 1 0 complexity complexity P, chi
Class II Division 2 5 Measurement Condition group group Total square
Class III 5 Localization Palatal 10 10 20 0.034*
Mean SD of impaction
Age (y) 18.16 7.32 Buccal 10 8 18
Bicortical 0 7 7
Impaction 1 10 0 10 \0.001*
The angle b, formed between the long axis of the sector
canine and the long axis of the lateral incisor, was also 2 9 0 9
3 1 10 11
measured. The canine vertical height was evaluated,
4 0 9 9
measuring the distance as the perpendicular distance 5 0 6 6
from the peak of the impacted canine to the occlusal Initial RR Present 3 15 18 0.002*
plane formed by a tangent to the incisal edge of the Absent 17 10 27
maxillary central incisor and the occlusal surface of the *Statistically significant at P \ 0.05.
maxillary first molar (Fig 2).23,29
Three trained orthodontists (L.E.A.G., G.A.R.M., and
Y.A.R.C.) evaluated the impaction sector and position The DICOM files were imported into 3-dimensional soft-
of the impacted canine in each CBCT image. Interob- ware (version 11.7; Dolphin Imaging, Chatsworth, Calif)
server concordance was assessed with the kappa test, to obtain and evaluate multiplanar and 3-dimensional
with perfect agreement (1.0). For continuous variables, reconstructions.
1 investigator (L.E.A.G.) performed all measurements Root lengths were measured in millimeters on the
twice, with a month interval. The intraobserver concor- same longitudinal axis from a perpendicular projection
dance was evaluated with the intraclass correlation coef- to the vestibular cementoenamel junction in the sagittal
ficient. Values higher than 0.9 (95% CI, 0.80-0.97) were section or mesial cementoenamel junction in the coronal
obtained. Additionally, random errors were calculated section up to the vertex of the radicular apices of the
with Dahlberg's formula.30 Dahlberg coefficients were central and lateral incisors adjacent to the impacted
smaller than 1 mm or 1 mm2 for all variables. canine (Figs 3 and 4). Incisor root areas in square
CBCT scans of all patients were taken (PaX-Uni 3D; millimeters were measured as well. In the sagittal
Vatech, Hwaseong, South Korea) set at 4.7 mA, section, the area was measured from the buccal
89 kV(p), voxel size of 0.125, and exposure time of cementoenamel limit to the palatal cementoenamel
15 seconds. Each field of view mode was 8 3 8 cm.2 limit (Fig 5). In the coronal section, the area included

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Arriola-Guill
en et al 31

Table IV. Measurements of the impacted canines according to orthodontic traction complexity
95% CI

Measurement Complexity n Mean SD P Mean difference Lower Upper

a angle ( ) Low 20 33.30 17.93 \0.001* 21.49 30.29 12.69
High 25 54.79 11.15
b angle ( ) Low 20 38.88 19.46 0.165 8.77 21.27 3.74
High 25 47.64 21.58
Height (mm) Low 20 11.02 5.00 0.606 0.64 3.13 1.85
High 25 11.66 3.24

*Statistically significant at P \ 0.05. Independent t test.

Fig 2. Measurement of angle a, angle b, and height h.

the path from the mesial to the distal cementoenamel in, 8 and 13 mm long, and 100 or 150 g of force (Den-
limits (Fig 6). In the axial sections, the area of RR was tos, Daegu, Korea), to perform intraosseous transalveo-
measured at the level of 2 sectors. The root length on lar traction. Activations of 4 to 5 mm were performed
the sagittal section was divided into thirds, and the areas every 4 to 8 weeks (Fig 9). A passive 0.017 3 0.025-
of the cervical and middle thirds in the axial sections in stainless steel archwire placed on the previously
were measured. aligned and leveled teeth was cinched distally of the
One rigid temporary anchorage device was installed. last molar in the anchorage, before the traction. After
The appliance included a palatal acrylic button soldered traction, CBCT images were taken to control the treat-
on the bands in the permanent first molars and a modi- ment. Then, the final phase was started. All necessary
fied palatal arch around the palatal surfaces of all procedures were performed to complete the orthodon-
maxillary teeth in 1.1-mm (0.043 in) or 1.2-mm tic treatment.
(0.047 in) stainless steel wire (Dentaurum, Ispringen, RR in each incisor was measured by subtracting the
Germany) with multiple palatal-occlusal-vestibular sol- initial value from the final value of length in millimeters
dered hooks in 0.028-in wire between the first molar and area in square millimeters in the 3 sections
and second premolar, and the second and first premo- evaluated.
lars, mesial to the first premolar and distal to the lateral
incisors (Figs 7 and 8). Vestibular hooks and device Statistical analyses
extensions allowed regulation of the buckles of closed All statistical analyses were performed using SPSS
helicoidal nickel-titanium coil springs, 0.010 3 0.036 software for Windows (version 19.0; IBM, Armonk,

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32 Arriola-Guill
en et al

Fig 3. Assessment of the root length in the sagittal plane. Fig 4. Assessment of the root length in the coronal plane.

NY). The data distribution was determined by Shapiro- incisors, and the location of the impacted canine (pala-
Wilk tests. When the distribution was not normal, tally displaced) had a significant influence on the RR area
comparisons of RR between groups were evaluated of the maxillary central incisor in the coronal section.
with Mann-Whitney U tests; otherwise, we used The impaction height was significant as well
t tests. Finally, a multiple linear regression model to (P \ 0.05), and the initial RR was also significant
determine the influence of each variable on RR was (P 5 0.003) regarding RR in the maxillary lateral incisor
applied. The significance level was set at P \ 0.05 (sagittal section). To further evaluate the specific influ-
for all tests. ence of canine impaction location, this variable was
categorized into 2 dummy variables: the first comparing
RESULTS bicortically impacted canines vs palatally and buccally
The RR of maxillary incisors in the sagittal and coro- displaced canines (P . 0.05), and the second comparing
nal sections showed no significant differences between palatally displaced vs bicortically and buccally impacted
groups. Altogether, the root length range of RR was 1 canines (P 5 0.012, for RR area of central incisors in the
to 1.5 mm, and the area range was 3 to 4 mm2 in both sagittal sections) (Tables VIII and IX).
groups (Tables V and VI). No significant differences
DISCUSSION
were found in the axial sections between groups;
likewise, the RR area was less than 2 mm2 in both Orthodontists face a great challenge when treating
groups (Table VII). patients with highly complex impacted maxillary ca-
Multivariate analysis using multiple linear regression nines,18 particularly when the treatment includes
with RR as the outcome variable did not show a signifi- impacted canines close to or in contact with the roots
cant influence on the complexity of orthodontic treat- of anterior teeth and when they are horizontally posi-
ment (P . 0.05). However, the variable sex had an tioned,25 because the risk for RR of incisors is higher.31
influence, specifically on the RR of the maxillary central For these reasons, the aim of this study was to determine

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Arriola-Guill
en et al 33

Fig 6. Assessment of the root area in the coronal plane.

Fig 5. Assessment of the root area in the sagittal plane. classification of Ericson and Kurol23,28 or a
modifications of it.29 In sagittal sections, the classifica-
the influence of the orthodontic traction complexity of tions take into account the height of canine impaction,
impacted maxillary canines on the RR of incisors. having as a reference the cusp tip or its root apex; addi-
The use of CBCT for patients with impacted canines tionally, in the axial section, some classifications eval-
before and during orthodontic treatment, specifically af- uate the position of the impacted canine in relation to
ter traction, is based on the ALARA principle.32 The the line of occlusion to classify it as palatally, buccally,
application of the same technique of traction, with or bicortically centered. In our study, the classification
nickel-titanium coil springs and reinforced anchorage of treatment complexity was made on the sagittal plane
ensures that the results can be compared between based on the impaction sector, classifying as most
groups, although the direction of traction changes for complex the impactions in sectors 3, 4, and 5 according
each patient.27 In addition, all patients were treated by to the method of Ericson and Kurol23,28 due to
1 expert orthodontist (G.A.R.M.), with more than 20 years their proximity to the midline. Regarding sector 3, we
of experience with this type of impaction, reducing the also included the measurement of a angle as a
possibility of operator bias in the study. classification factor and defined as complex cases
There are few methods that classify the complexity of those with the highest horizontal tendency: ie, when
orthodontic traction of impacted canines,23,28 and even the angle was greater than 40 . The location in the
fewer using CBCT.21 Moderate concordance has been re- axial and coronal sections was considered as well,
ported when these methods have been compared with classifying the cases as palatally, buccally, or
the clinical criteria of experts in this area.21 The criteria bicortically impacted, depending on the position of the
to evaluate computed tomography scans to define the crown of the impacted canine in relation to the incisor
complexity of a patient with impacted canines in radius: ie, the occlusion line and based on a clear
the sagittal sections are frequently based on the tomographic examination in both cuts, which was

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34 Arriola-Guill
en et al

Fig 7. Graphic representation of the anchor including buccal extensions to favor the traction of
impacted canines.

Fig 8. Example of impacted canine traction and rigid temporary anchorage device placed on perma-
nent first molars with rigid palatal acrylic button.

reliable as shown by perfect interobserver agreement impacted canines were included only in the high
using the kappa test. Patients with bicortically complexity group. Additionally, in all cases of close
impacted canines (in the middle of the 2 cortical proximity or physical contact, RR was observed before
bones)17,18 (Fig 10) were defined as more complex, due starting canine traction. However, after finishing
to their proximity to the incisor roots (close to the traction, this RR did not increase significantly and did
midline, sectors 4 and 5)23,28 before orthodontic not show differences compared with the RR after
treatment. Although buccally and palatally impacted traction in the low complexity group. Nevertheless,
canines were included in both groups, bicortically future studies including only subjects with bicortical

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Arriola-Guill
en et al 35

Fig 9. Example of bilateral impacted canine traction.

Table V. Comparison of RR of maxillary incisors and area according to orthodontic traction complexity, sagittal
section
Low complexity (n 5 20) High complexity (n 5 25) 95% CI

Mean Lower Upper

Tooth Measurements Mean SD Mean SD difference limit limit P
Maxillary lateral incisor Root resorption (mm) 1.27 1.09 1.28 0.95 0.01 0.63 0.60 0.964
Resorption area (mm2) 2.93 3.09 3.15 2.52 0.22 1.91 1.46 0.791
Maxillary central incisor Root resorption (mm) 1.45 1.18 1.56 1.03 0.11 0.78 0.55 0.731
Resorption area (mm2) 3.62 3.14 3.44 3.18 0.17 1.74 2.09 0.858
Independent t test.

Table VI. Comparison of RR of maxillary incisors and area according to orthodontic traction complexity, coronal
section
Low complexity (n 5 20) High complexity (n 5 25) 95% CI

Mean Lower Upper

Tooth Measurement Mean SD Mean SD difference limit limit P
Maxillary lateral incisor Root resorption (mm) 1.58 1.03 1.28 1.13 0.30 0.35 0.96 0.355
Resorption area (mm2) 3.26 2.37 2.45 1.85 0.81 0.46 2.07 0.205
Maxillary central incisor Root resorption (mm) 1.55 1.05 1.32 1.02 0.23 0.39 0.86 0.454
Resorption area (mm2) 3.47 3.41 4.08 3.09 0.61 2.57 1.35 0.532
Independent t test.

2
Table VII. Comparison of the area (mm ) of RR of maxillary incisors at the cervical and middle thirds according to
orthodontic traction complexity, axial section
Low complexity (n 5 20) High complexity (n 5 25) 95% CI

Mean Lower Upper

Tooth Measurement Mean SD Mean SD difference limit limit P
Maxillary lateral incisor Cervical third 0.43 0.53 0.99 1.42 0.57 1.24 0.11 0.166
Middle third 0.81 0.94 1.48 1.80 0.67 1.57 0.23 0.534
Maxillary central incisor Cervical third 0.69 1.00 1.15 1.62 0.46 1.30 0.37 0.341
Middle third 1.36 1.91 1.67 2.70 0.31 1.75 1.13 0.768
Mann-Whitney U test.

impaction should be carried out to confirm our results. would not have an increased risk of RR of the anterior
Canine impaction height is not an exclusive complexity teeth because the canine has no contact with their
criterion, since an impaction with low height but close roots. Orthodontists frequently treat impacted canines
to the midline would be difficult to treat, whereas a with RR in the maxillary incisors.33 This condition is
patient with a higher canine impaction in sector 1 only a caution factor, demanding the use of efficient

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36 Arriola-Guill
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Table VIII. Multiple linear regression analysis of RR (mm) and area of maxillary incisors, sagittal section
Maxillary lateral incisor Maxillary central incisor

Predictor variable b P b P
Root resorption (mm)
Constant 0.298 0.206
Orthodontic traction complexity 0.01 0.970 0.68 0.085
Sex 0.03 0.867 0.29 0.173
Age 0.07 0.698 0.02 0.901
Duration of traction 0.18 0.366 0.11 0.589
Dummy 1 (palatine and buccal vs bicortical) 0.33 0.200 0.07 0.796
Dummy 2 (palatine vs buccal and bicortical) 0.24 0.357 0.39 0.170
Sector of impacted canine 0.43 0.218 0.33 0.364
Initial root resorption 0.78 0.003* 0.03 0.896
Angle a of impacted canine 0.45 0.303 0.63 0.165
Angle b of impacted canine 0.58 0.062 0.09 0.805
Height of impacted canine 0.23 0.486 0.58 0.107
Initial root length 0.15 0.535 0.07 0.822
r2 0.197 0.155
Area of root resorption (mm2)
Constant 0.082 0.029*
Orthodontic traction complexity 0.10 0.784 0.70 0.056
Sex 0.14 0.489 0.49 0.010*
Age 0.06 0.747 0.01 0.925
Duration of traction 0.15 0.442 0.06 0.727
Dummy 1 (Palatine and Buccal vs Bicortical) 0.30 0.219 0.19 0.385
Dummy 2 (Palatine vs Buccal and Bicortical) 0.01 0.982 0.59 0.012*
Sector of impacted canine 0.42 0.219 0.29 0.340
Initial root resorption 0.34 0.168 0.27 0.249
Angle a of impacted canine 0.71 0.094 0.76 0.053
Angle b of impacted canine 0.53 0.084 0.05 0.864
Height of impacted canine 0.05 0.882 0.69 0.024*
Initial root length 0.04 0.870 0.25 0.308
r2 0.242 0.380
Dummy 1, location of impacted canine (palatine and buccal vs bicortical).
Dummy 2, location of impacted canine (palatine vs buccal and bicortical).
*Statistically significant at P \ 0.05.

biomechanics with optimal forces to prevent greater health that could lead to tooth loss. The RR was approx-
radicular resorption. In the high complexity treatment imately 1 to 1.5 mm and was smaller than 4 mm2 in the
group, 60% of the patients had initial RR, making treat- sagittal and coronal sections; for the axial section, no
ment even more difficult, compared with 15% of the pa- significant differences were found.
tients with this condition in the low complexity group. The multivariate analysis did not identify a common
We considered that the initial RR of adjacent permanent risk factor, including the influence of the orthodontic
teeth during maxillary canine eruption could be, accord- traction complexity. We only detected the influence of
ing to the literature, more an effect of the physical con- sex, indicated by a higher risk of resorption in male pa-
tacts between the erupting canine and the adjacent tients. The effect of sex is controversial and considered in
tooth than the action of the dental follicle size.34,35 few studies evaluating RR after traction of impacted ca-
Likewise, although in the high complexity group the nines.36-38 One study found no significant differences
RR condition was more frequent at the beginning of regarding sex.36 Recent studies have concluded that af-
treatment, the RR after traction was similar in both ter conventional orthodontic treatment without treating
groups; therefore, it is not apparently a risk factor. impacted canines, sex does not influence RR of the inci-
However, more studies evaluating this condition must sors.39,40 Nevertheless, this information cannot be
be carried out. extrapolated to treatments with canine impaction. In
The amount of RR in both groups (high complexity vs our study, the influence of sex was seen only for some
low complexity) was similar and smaller than 2 mm. This comparisons: specifically, the maxillary central incisor.
amount of RR does not depict risk for oral or tooth However, an explanation that supports the appearance

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Arriola-Guill
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Table IX. Multiple linear regression analysis of RR and area of maxillary incisors, coronal section
Maxillary lateral incisor Maxillary central incisor

Predictor variable b P b P
Root resorption (mm)
Constant 0.939 0.047*
Orthodontic traction complexity 0.34 0.330 0.52 0.120
Sex 0.18 0.334 0.45 0.020*
Age 0.20 0.211 0.06 0.704
Duration of traction 0.37 0.054 0.02 0.914
Dummy 1 (palatine and buccal vs bicortical) 0.18 0.424 0.54 0.053
Dummy 2 (palatine vs buccal and bicortical) 0.03 0.888 0.29 0.207
Sector of impacted canine 0.11 0.719 0.31 0.305
Initial root resorption 0.30 0.290 0.17 0.449
Angle a of impacted canine 0.40 0.321 0.30 0.427
Angle b of impacted canine 0.07 0.827 0.24 0.417
Height of impacted canine 0.05 0.862 0.53 0.078
Initial root length 0.53 0.022* 0.26 0.384
r2 0.338 0.387
Area of root resorption (mm2)
Constant 0.083 0.034*
Orthodontic traction complexity 0.14 0.665 0.40 0.255
Sex 0.50 0.014* 0.63 0.003*
Age 0.22 0.155 0.19 0.236
Duration of traction 0.22 0.200 0.04 0.815
Dummy 1 (palatine and buccal vs bicortical) 0.14 0.513 0.28 0.228
Dummy 2 (palatine vs buccal and bicortical) 0.05 0.815 0.23 0.329
Sector of impacted canine 0.01 0.980 0.23 0.470
Initial root resorption 0.16 0.435 0.10 0.627
Angle a of impacted canine 0.09 0.811 0.02 0.959
Angle b of impacted canine 0.42 0.139 0.49 0.086
Height of impacted canine 0.10 0.731 0.43 0.164
Initial root length 0.26 0.225 0.31 0.171
r2 0.412 0.332
Dummy 1, location of impacted canine (palatine and buccal vs bicortical).
Dummy 2, location of impacted canine (palatine vs buccal and bicortical).
*Statistically significant at P \ 0.05.

Fig 10. Example of maxillary impacted canine in intermediate position or centered bicortically.

of the RR in this tooth can only be based on future influence should have been consistent across all CBCT
studies with larger samples of both sexes. If any scans analyzed and could be present in both incisors
predictor variable is truly a risk factor for RR, its and not only one.

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38 Arriola-Guill
en et al

In this study, the null hypothesis was accepted: there 16. Miralles R. Canine-guide occlusion and group function occlusion
is no significant difference in the amount and area of RR are equally acceptable when restoring the dentition. J Evid Based
Dent Pract 2016;16:41-3.
of the maxillary incisors after orthodontic traction of
17. Chaushu S, Kaczor-Urbanowicz K, Zadurska M, Becker A. Predis-
impacted canines with different levels of complexity. posing factors for severe incisor root resorption associated with
This RR behavior could allow the orthodontist to treat impacted maxillary canines. Am J Orthod Dentofacial Orthop
patients with impacted canines in complex positions, 2015;147:52-60.
since there is not a greater risk of RR. 18. Cuminetti F, Boutin F, Frapier L. Predictive factors for resorption of
teeth adjacent to impacted maxillary canines. Int Orthod 2017;15:
54-68.
CONCLUSIONS 19. Yan B, Sun Z, Fields H, Wang L. Maxillary canine impaction in-
The orthodontic traction complexity of impacted creases root resorption risk of adjacent teeth: a problem of physical
proximity. Orthod Fr 2015;86:169-79.
maxillary canines is not a risk factor for greater RR of
20. Al-Zoubi H, Alharbi AA, Ferguson DJ, Zafar MS. Frequency of
the maxillary incisors. impacted teeth and categorization of impacted canines: a retro-
spective radiographic study using orthopantomograms. Eur J
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