CASE REPORT

A simple approach to correct ectopic

eruption of maxillary canines

Nelson Muchac
Jamille Barros Ferreira,a Giordani Santos Silveira,b and Jose
Rio de Janeiro and Belo Horizonte, Brazil

This case report describes the orthodontic treatment of a patient with severe crowding; the maxillary right ca-
nines were ectopic, positioned far to the buccal side, and superimposed on the lateral incisors in near-
transposition. Treatment included extraction of the 4 first premolars. A transpalatal bar was used as an
anchorage device, and beta-titanium T-loop springs (0.019 3 0.02500 ) were used to better control the ideal force
applied to retract the maxillary canines. A segmental T-loop spring was used as if it were a modified system of the
segmental archwire technique. After the canines were retracted and space created for the anterior teeth, the
latter were included in the treatment and the treatment was finished in the usual manner. Excellent results
were achieved, both esthetic and functional. The treatment choices and their straightforward approach were
appropriate, yielding predictable and stable results in the long term. (Am J Orthod Dentofacial Orthop
2019;155:871-80)

T
he ectopic impaction and eruption of permanent crowding associated with canine ectopic eruption
maxillary canines are frequent and extremely chal- located buccal to the dental arch further motivates pa-
lenging conditions in dental practice.1 One-third tients to seek orthodontic treatment.6,7
of impacted canines are located buccal to the dental In the present case report we describe the orthodontic
arch,2 and their etiology is related to a deficient dental treatment of a female patient with severe dental
arch perimeter.3 crowding, with maxillary canines positioned excessively
The eruption path of the maxillary permanent canine to buccal (ectopic) and superimposed on the lateral inci-
is not only long and winding, but slightly buccal in rela- sors in near-transposition. The treatment involved ex-
tion to the dental arch. Moreover, its eruption occurs af- tracting the 4 first premolars, the use of a transpalatal
ter that of the lateral incisor and the first premolar. bar and the use of segmental archwires with T loops
Therefore, any approximation between the roots of these with helicoids for the retraction of the ectopic canines.
teeth decreases the space available for the canine and At the end of treatment, the aims were achieved with
may cause their intraosseous retention or ectopic erup- optimal esthetic balance as well as excellent occlusal
tion, usually manifested by an exaggerated buccal relationships, which provided outstanding long-term
position.4 stability.
Teeth alignment plays an important role in facial es-
thetics and facial harmony,5 and the presence of maxil- DIAGNOSIS AND ETIOLOGY
lary dental crowding is esthetically less acceptable when
the 4 maxillary incisors are misaligned. The presence of A 13-year-9-month-old girl presented for clinical
care at the University's Orthodontics Program, accompa-
a
nied by her mother, with the chief complaint of mis-
Department of Pediatric Dentistry and Orthodontics, Universidade Federal do
Rio de Janeiro, Rio de Janeiro, Brazil. aligned teeth. According to her medical history she was
b
Department of Dentistry, Pontif
ıcia Universidade Cat

olica de Belo Horizonte, in overall good health. The clinical examination revealed
Belo Horizonte, Minas Gerais, Brazil. a slightly convex facial profile with a proportional lower
c
Department of Orthodontics, Universidade Federal Fluminense, UFF, Niteroi,
Rio de Janeiro, Brazil. third of the face, diminished nasolabial angle, slight pro-
All authors have completed and submitted the ICMJE Form for Disclosure of Po- trusion of the lips and normal display of the maxillary in-
tential Conflicts of Interest, and none were reported. cisors on smiling (Fig 1). During the intake interview the
Address correspondence to: Jamille Barros Ferreira, Rua Abdon Arroxelas, 410/
102, Bloco C, Ponta Verde, Macei
o, AL, CEP: 57.035-380, Brazil; e-mail, habit of onychophagia was reported. The mandibular
jamillebarros@hotmail.com. closure pattern showed no deviation and neither did
Submitted, September 2017; revised and accepted, November 2017. the temporomandibular dysfunction.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. The presence of the right maxillary primary canine
https://doi.org/10.1016/j.ajodo.2017.11.046 was noted, as well as space deficiency in the maxillary
871
872 Ferreira, Silveira, and Mucha

Fig 1. Pretreatment photographs.

Fig 2. Pretreatment dental casts.

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Ferreira, Silveira, and Mucha 873

Fig 3. Pretreatment radiographs and tracing. A, Lateral cephalometric radiograph; B, lateral cephalo-
metric tracing; C, panoramic radiograph; D, periapical radiographs of the maxillary anterior dentition.

arch of approximately 15 mm and severe crowding of

the anterior teeth. Furthermore, the maxillary canines Table. Cephalometric measurements
presented virtually superimposed buccal to the maxillary
Before After 4-year
lateral incisors or nearly transposed. The mandibular Measurement Norm treatment treatment follow-up
arch presented with moderate crowding of the anterior Age 14 y 6 mo 17 y 21 y 2 mo
teeth with a space deficiency of approximately 6 mm Skeletal pattern
and curve of Spee of 1 mm. When in occlusion, the SNA ( ) 82 85 86 86
maxillary laterals showed a dental crossbite, which ap- SNB ( ) 80 83 83 83
ANB ( ) 2 2 3 3
peared more severe on the right side, in addition to an Wits (mm) 0-2 4 1 1
overbite and an overjet of 2 mm. The upper and lower Convexity ( ) 0 2 4 4
dental midlines coincided with each other and with the Y-axis ( ) 59 63 60 62
face, and a Class I molar relationship was present. Both Facial angle ( ) 87 85 87 86
the maxilla and the mandible showed severe lack of SN-GoGn ( ) 32 29 28 28
FMA 25 28 26 26
gingival leveling in the anterior segments. The left Dental pattern
mandibular central incisor was the most buccally posi- IMPA ( ) 90 102 96 97
tioned tooth and presented with some mild gingival 1.NA ( ) 22 30 20 22
retraction (Fig 2). 1.NA (mm) 4 7 4 4
Dental radiographic examination revealed the pres- 1.NB ( ) 25 36 28 28
1.NB (mm) 4 6 3, 5 3, 5
ence of all permanent teeth and the right maxillary 1.1 ( ) 130 114 130 127
primary canine. The third molars were in the final stage 1.SN ( ) 103 115 109 109
of crown formation but lacked space for their complete Profile
eruption. Root contours seemed normal and no UL-S line (mm) 0 2 0 0
pathologic lesions were detected (Fig 3). LL-S line (mm) 0 4 0 0

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874 Ferreira, Silveira, and Mucha

Fig 4. Mechanical approach.

The cephalometric analysis (Fig 3; Table) disclosed a TREATMENT ALTERNATIVES

good relationship between maxilla and mandible (ANB Owing to the presence of severe localized crowding in
2 ), with a slight protrusion of the maxilla (ANS 85 ) the anterior area of both dental arches, a slight labial
and mandible (SNB 83 ), a good vertical relationship inclination of the incisors, an excellent Class I molar
(GoGn.SN 30 , FMA 28 , Y-axis 63 ), and a slight pro- relationship, and a slightly convex facial profile, we pro-
jection of the upper and lower lips relative to the posed orthodontic treatment with extraction of the 4
Steiner S-line (S-LS 2 mm, S-LI 4 mm). The maxillary first premolars and the use of fixed appliances, followed
incisors were projected labially (1-NA 7 mm, 1.NA by retraction of the upper canines with proper anchorage
30 , 1.SN 116 ) and the mandibular incisors were control.
slightly proclined to labial (1-NB 6 mm, 1.NB 36 , If the dental arches were to be aligned and leveled
IMPA 102 ). with no concern for extractions or the distal movement
of posterior teeth, the treatment might have resulted
in a protruding facial profile as well as dental protru-
TREATMENT OBJECTIVES sions.
The treatment objectives were to: (1) improve facial Any approach involving the distal movement of teeth
profile; (2) eliminate upper and lower crowding and to create space by using different mechanisms (eg, skel-
create space for maxillary canines; (3) maintain Class etal anchorage) might prove challenging and time
I molar relationship and establish normal canine consuming and would inevitably require the extraction
relationship; (4) correct lateral incisor crossbite; (5) of the third molars.
maintain overjet and overbite; (6) obtain functional oc- Considering the significant space deficiency, notably
clusion with stable occlusal contacts in centric relation in the upper arch, the facial features, the lack of spaces
and during protrusion and laterality movements, and for the third molars, and the optimal Class I molar rela-
(7) ensure stability results. tionship, any alternate treatment that did not involve the

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Ferreira, Silveira, and Mucha 875

Fig 5. Posttreatment photographs.

extraction of the first 4 premolars would have been un- and distal legs of the T-loops were made at different
predictable and questionable, as well as complex. heights, because the mesial was shorter than the
distal leg, to ensure that the extrusion force was as
TREATMENT PROGRESS biologic as possible (Fig 4). Gradually this difference
The treatment started with placement of a fixed between the heights of the legs was diminished,
transpalatal bar on the first maxillary molars. These mo- providing extrusion and leveling of the canines in
lars received headgear tubes if greater anchorage control the dental arch.
was needed, and 0.022 3 0.02800 standard edgewise To maintain the omegas away from the second molar
twin brackets. tubes and to provide greater activation during canine
In the upper arch to create space for the maxillary retraction, additional omega loops were made to shorten
canines the primary canines and first premolars were ex- the spring horizontal segment (Fig 4). Very light force
tracted. Tubes were bonded to the second molars and was applied when the springs were activated to move
brackets to the upper second premolars and canines. the canines lingually and distally and to extrude them
Next, springs in the T-loop shape with helicoids were without compromising the bone and gingival structure.
bent from rectangular tungsten-molybdenum alloy (beta- After the maxillary teeth had been retracted and
titanium) wire, 0.019 3 0.02500 , as shown in Figure 4. consequently the required space had been created in
The springs were fitted from the canines to the the anterior area, all maxillary teeth were included in
second molars, and the omegas were activated away the treatment, aligned and leveled with the use of
from the tubes of the second molars. The mesial 0.01400 , 0.01800 , and 0.01900 3 0.02500 nickel-titanium

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876 Ferreira, Silveira, and Mucha

Fig 6. Posttreatment dental casts.

Fig 7. Posttreatment radiographs and tracing. A, Lateral cephalometric radiograph; B, lateral cepha-
lometric tracing; C, panoramic radiograph; D, periapical radiographs of the maxillary anterior dentition.

June 2019  Vol 155  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Ferreira, Silveira, and Mucha 877

wires. It proved necessary, to create more space for the

right upper lateral incisor, to use an open nickel-
titanium spring compressed between the canine and
central incisor. Thereafter, the right upper lateral incisor
was included with the alignment and leveling archwires.
In the mandibular arch, the appliance was placed on
all teeth with the use of the same system, except for the
first premolars, which were removed. The mandibular
teeth were aligned and leveled with the use of 0.01400 ,
0.018,00 and 0.01900 3 0.02500 nickel-titanium wires.
Canine retraction was performed by extending elasto-
meric chains from the posterior teeth to the canines
using 0.019 3 0.02600 rectangular stainless steel arch-
wires. Next, the mandibular incisors were included in
the alignment and leveling procedure. Minor remaining
spaces were closed with the use of elastomeric chains.
Owing to some mesial tipping of the roots of the lower
canines (Figs 1-3), bracket rebonding of these teeth was Fig 8. Superimposed cephalometric tracings.
carried out to their best possible positions and then a
new leveling of the lower dental arch enabled a analysis (Fig 7; Table) and superimposition of the trac-
satisfactory root parallelism of these teeth (Figs 5-7). ings (Fig 8) indicate that the anteroposterior relationship
Finishing was accomplished by means of symmetric between maxilla and mandible (ANB 3 , ANS 86 , SNB
and coordinated archwires, maintaining the original 83 ) was maintained, as well as the facial proportions
dental arches form with the use of 0.019 3 0.02600 stain- (SN-GoGn 27 , FMA 26 , Y-axis 60 ).
less steel archwires. This phase required enhancing Improvement was noted in the facial profile and
buccal root torque in the lateral maxillary incisors. position of the lips (S-LS 0 mm, S-LI 0 mm). Superimpo-
Removable wraparound retainers were used on the sition showed a slight uprighting of the lower incisors
maxilla, and fixed 0.02800 stainless steel wire retainers with the upper incisors remaining in virtually the same
were bonded only to the canines on the mandibular arch. position. Furthermore, there was some loss of propor-
tional anchorage in the upper and lower molars (Fig 8).
Extracting the first 4 premolars enabled excellent
TREATMENT RESULTS results with superior stability 4 years after removal of
Outstanding results were achieved with an improved the fixed appliance (Fig 9).
facial profile and smile harmony (Fig 5). The molar rela-
tionship was preserved in Class I and occlusal contacts DISCUSSION
were obtained between all of the other teeth, especially Orthodontists often encounter dental eruption
the canines. Overjet and overbite were maintained and abnormalities during the development of dentition. These
the midlines remained coincident with each other and abnormalities are primarily related to ectopia. Eruption
with the face (Figs 5 and 6). A mutually protected disorders associated with transposition occur in the maxilla
occlusion was obtained with stable contacts in centric in 76% of cases, predominantly involve canines (90%),
relation and efficient protrusive movements, as well as premolars (71%), or lateral incisors (20%), and defy early
right and left laterality movements. diagnosis owing to their multifactorial character.8-10
A balanced gingival contour was obtained in both In the present case, a pseudotransposition was re-
dental arches, particularly by leveling the gingival vealed by radiography, which was characterized by
margin of the left central mandibular incisor with the crown ectopia of the maxillary canine, positioned mesial
other incisors. A mild unevenness can be seen between in relation to the lateral incisor and with a root apex
the zeniths of the maxillary lateral incisors, but with located distal to the lateral incisor.8 Esthetically and
no significant esthetic impairment given a significant functionally, it is recommended in these cases that the
overall periodontal improvement (Fig 6). transposed teeth be moved to their normal position in
Radiographic analysis (Fig 7) revealed a good appear- the dental arch.11,12
ance of the ridges and trabecular bone, as well as appro- Early diagnosis and interception at an optimal time is
priate root parallelism. The cephalometric and tracing the best approach for intervention in these cases.13

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878 Ferreira, Silveira, and Mucha

Fig 9. Photographs at the 4-year follow-up.

Corrective treatment was the choice in the present case initial stages (Fig 4), allowed proper control of the force
because of the advanced stage of the dentition when system16-18 with good tooth movement at a lower
the patient sought treatment. Important factors were friction rate, no undesirable effects on the adjacent
taken into account in determining the ectopia treatment teeth,14,17,18 and appropriate anchorage control.17-19
plan for maxillary canines. The positioning of crowns After canine retraction, the treatment was conducted
and roots of canines and upper lateral incisors, the conventionally.
absence of root resorption, the degree of crowding, Appropriate anchorage control in the upper arch
and the patient's motivation were noted. was established with the use of a transpalatal arch and
Different types of mechanisms have been described the posterior teeth during canine retraction. Studies
for correcting tooth transposition with distinct levels have shown that the use of an isolated transpalatal
of severity.9,14,15 Therefore, to preserve supporting arch does not provide maximum anchorage in cases of
tissues and prevent dental trauma and resorption, in premolar extraction when incisors are retracted.20-22
addition to performing the treatment in a predictable However, the anchorage provided by the transpalatal
way and within a shorter period of time, we decided to arch may be considered to be equivalent to skeletal
extract the first 4 premolars and place a spring in a anchorage when retracting only canines.23,24
modified segmental archwire to ensure the proper The mild improvement in the gingival retraction of
positioning of the maxillary canines in the dental arch. the lower left central incisor which was positioned
Canine retraction with a T-loops with helicoids on a more to buccal resulted from a slight uprighting of these
tungsten molybdenum (beta-titanium) alloy wire, espe- anterior lower teeth and the elimination of possible
cially with the spring legs at different heights in the occlusal traumas.25,26

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Ferreira, Silveira, and Mucha 879

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professionals and laypeople to altered maxillary incisor crowding.
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and overjet, occlusal contacts in all teeth, and a coinci- 6. Bernab
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10. Shapira Y, Kuftinec MM. Maxillary tooth transpositions: character-
It should be emphasized that a proper biomechanical istic features and accompanying dental anomalies. Am J Orthod
control, with simple procedures, combined with the need Dentofacial Orthop 2001;119:127-34.
to create spaces for tooth movement (which includes the 11. Shapira Y, Kuftinec MM. Tooth transpositions–a review of the
need for extractions), are some of the essentials of ortho- literature and treatment considerations. Angle Orthod 1989;59:
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12. Shapira Y, Kuftinec MM, Stom D. Maxillary canine-lateral incisor
Planning in this case proved to be satisfactory to the transposition–orthodontic management. Am J Orthod Dentofacial
extent that the patient's esthetics and balanced occlusal Orthop 1989;95:439-44.
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and transposition with a segmented-arch technique. J Clin Orthod
Based on the favorable results, it would be safe to 2001;35:79-86.
assert that the treatment adopted in this clinical case 15. Gebert TJ, Palma VC, Borges AH, Volpato LE. Dental transposition
was the most appropriate. Because of the large space of canine and lateral incisor and impacted central incisor treat-
ment: a case report. Dental Press J Orthod 2014;19:106-12.
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ACKNOWLEDGEMENTS
Orthod 2014;19:126-41.
This study was financed in part by the Coordenaç~ao 20. Diar-Bakirly S, Feres MF, Saltaji H, Flores-Mir C, El-Bialy T. Effec-
de Aperfeiçoamento de Pessoal de N
ıvel Superior - Brasil tiveness of the transpalatal arch in controlling orthodontic
anchorage in maxillary premolar extraction cases: A systematic re-
(CAPES) - Finance Code 001.
view and meta-analysis. Angle Orthod 2016;87:147-58.
21. Zablocki HL, McNamara JA Jr, Franchi L, Baccetti T. Effect of the
SUPPLEMENTARY DATA transpalatal arch during extraction treatment. Am J Orthod Dento-
facial Orthop 2008;133:852-60.
Supplementary data related to this article can be
22. Liu YH, Ding WH, Liu J, Li Q. Comparison of the differences in
found online at https://doi.org/10.1016/j.ajodo.2017. cephalometric parameters after active orthodontic treatment
11.046. applying mini-screw implants or transpalatal arches in adult pa-
tients with bialveolar dental protrusion. J Oral Rehabil 2009;36:
687-95.
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