CASE REPORT

Orthodontic repositioning of a lingually

positioned transmigrated mandibular
canine
Andrea Scribante, Sergio Beccari, Giovanna Beccari, Maurizio Pascadopoli, Paola Gandini,
and Maria Francesca Sfondrini
Pavia, Italy

This case report presents the successful orthodontic repositioning of a transmigrated and lingually positioned
mandibular canine with conventional mechanics. Treatment began with the aim of creating space for the four
permanent canines that had not yet erupted. Cervical headgear, mesial slice, and extraction of the deciduous
teeth were executed, but only the right canines erupted; moreover, the mandibular left canine had become
lingually transmigrated. Multibracket therapy was performed with the orthodontic repositioning of both left ca-
nines in 2 steps. They were repositioned, and good alignment was obtained. To our knowledge, this is the first
case report describing the orthodontic repositioning of a lingually transmigrated canine with conventional double-
arch mechanics. This treatment was successful and without significant complications, even though this
approach can be challenging and time-consuming. (Am J Orthod Dentofacial Orthop 2023;163:272-84)

T
he orthodontic challenge related to maxillary and mandibular incisors, mandibular traumas in the area of
mandibular canine impaction is commonly eruption of the canines, odontomes, cysts, retained
encountered in clinical practice. However, trans- root stumps, and shape anomalies of adjacent teeth.5
migration is not as frequent and presents different treat- Anatomic variations referred to as sella turcica bridging
ment challenges. Impaction is the failure of tooth have been associated with dental anomalies,6,7 with
eruption 1 year after its physiological period. Transmi- buccally and palatally impacted maxillary canines being
gration is the mesial pathway of eruption that can lead the most common of these variations.8,9
the tooth to cross the midline.1 According to Javid’s defi- Clinicians attempt to rescue mandibular canines
nition, a transmigrated tooth crosses the midline with through various techniques if the adjacent incisors are
more than half its total length.2 in a normal position and, if possible, try to create suffi-
Canines fulfill important roles from both functional cient space for their repositioning.10 If these conditions
and esthetic points of view,3 and their absence implies are not present, other alternatives can be considered.11
significant orthodontic and surgical problems.4 The re- The orthodontic repositioning of transmigrated mandib-
ported incidence of impacted mandibular canines ular canines in the dental arch is difficult. Because of pa-
ranged between 0.92% and 5.1%, compared with a ratio tient preference, surgical extraction is performed in most
of 1:20 for maxillary impaction. In contrast, the inci- situations. This may be one of the reasons that very few
dence of transmigration ranged between 0.10% and patients treated with the surgical-orthodontic approach
0.31%. Etiology includes hereditary factors, endocrine are present in the literature.12-18
dysfunctions, cancer, vestibular inclination of In this case report, we explain the procedures for the
orthodontic repositioning of a lingually positioned
From the Unit of Orthodontics and Pediatric Dentistry, Section of Dentistry,
Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University transmigrated mandibular canine using conventional
of Pavia, Pavia, Italy. mechanics.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Maurizio Pascadopoli, Unit of Orthodontics and Pae- DIAGNOSIS AND ETIOLOGY
diatric Dentistry, Section of Dentistry, Department of Clinical, Surgical, Diag-
nostic and Paediatric Sciences, University of Pavia, Piazzale Golgi 2, Pavia A 13-year-old male patient was referred to our ortho-
27100, Italy; e-mail, maurizio.pascadopoli01@universitadipavia.it. dontics clinic by his general dentist. He was in good gen-
Submitted, February 2021; revised and accepted, September 2021. eral health, and his medical history was notable only for
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved. a known allergy to dust mites. Extraoral photographs
https://doi.org/10.1016/j.ajodo.2021.09.022 showed a convex facial profile because of mandibular
272
Scribante et al 273

Fig 1. Initial facial and intraoral photographs.

deficiency (Fig 1). Based on the intraoral photographs Based on the lateral cephalometric radiograph and its
and the study models (Figs 1 and 2), the patient ap- related tracing (Fig 3; Table), a skeletal Class II pattern
peared to have mixed dentition. A mild Class II Division was noted (ANB, 5.1 ) with a correct position of the
2 malocclusion was present, with a molar Class II rela- maxilla (SNA, 80.9 ) and a retruded mandible (SNB,
tionship on the right side and a weak Class I on the 75.8 ). We observed a good vertical relationship (SN-
left side. A deep overbite was present, with a slight GoGn, 30.5 ), with a normal divergence of bispinal
malposition of maxillary incisors and small-sized maxil- and mandibular planes (PP-GoGn, 17.4 ), orthognathic
lary lateral incisors. The specific issue of hypoplastic in- residual growth pattern (Ar-Go-N, 49.6 ; N-Go-Gn,
cisors made us consider a restorative approach for these 67.2 ) and a slightly modified inclination of maxillary
teeth after the orthodontic treatment to close spaces and and mandibular incisors (U1-PP, 102.7 ; IMPA 94.6 ).
achieve the best esthetic result. The mandibular arch Leonardi et al6 have suggested an association be-
presented mild crowding that allowed for the possibility tween sella turcica bridging and dental anomalies,
of taking advantage of leeway space (Figs 1 and 2). including the potential ectopic eruption of the perma-
The panoramic radiograph (Fig 3) revealed unfavor- nent teeth.7 Therefore, we performed a lateral skull
able eruption pathways for the permanent canines, radiographic examination of sella turcica to evaluate
particularly the left canines. The lack of a prominent the presence of sella turcica bridging. Three points
labial bulge and the lateral cephalometric radiograph were traced: dorsum sellae (DS), tuberculum sellae
suggested that the maxillary canines were in a palatal (TS), and the farthest point on the inner wall of the sella
position. Moreover, the lateral cephalometric radiograph (PS). Two distances were calculated between these
did not show the mandibular canine in the symphysis, points: the interclinoid distance (DS-TS) and the sella
suggesting it was located lingually. diameter (TS-PS). The DS-TS was then compared with

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
274 Scribante et al

Fig 2. Initial study models.

the TS-PS. In this case report, the patient presented a Deciduous tooth removal has been shown to be suc-
DS-TS (0.9 cm) that was less than three-quarters of the cessful in inducing eruption and, in some patients, even
TS-PS (1.35 cm) (Fig 4), suggesting a partial calcification horizontal movement of the cusp in a distal direction.19
of the interclinoid ligament, known as bridging, con- In the maxillary arch, preventive treatment included us-
firming the unfavorable pathway of the eruption of the ing cervical headgear associated with extractions of the
permanent canines.8,9 maxillary first primary molars.
Because of the presence of mixed dentition, we In the mandibular arch, extractions of deciduous ca-
decided to start the orthodontic therapy with phase 1, nines and primary maxillary first molars, and the mesial
which lasted only 9 months. After a brief intermission slice of the primary second molars were extracted.
of about 2 months, a decision was made to progress to
phase 2 of therapy when the patient presented perma- PHASE 1 TREATMENT PROGRESS
nent dentition. In the maxillary arch, we used a cervical headgear
with an anterior biteplane, together with the extractions
PHASE 1 TREATMENT OBJECTIVES of the maxillary first primary molars. In the mandibular
The treatment objectives of the first therapeutic arch, the mesial slice of the primary second molars was
phase were as follows: (1) to promote the correct executed in addition to the extractions of deciduous
pathway of eruption for maxillary and mandibular ca- canines.
nines and their correct positioning in dental arches, (2) After approximately 9 months of therapy, we per-
to establish a correct Class I dental relationship, (3) to formed a periapical radiograph of the permanent
establish a correct Class I skeletal relationship, and (4) mandibular canines (Fig 5, A), revealing a normal
to improve the deep overbite. pathway of eruption for the permanent mandibular right
canine, whereas there was a worsening in the eruption
pathway of the contralateral resulting in a horizontal
PHASE 1 TREATMENT ALTERNATIVES
inclination.
When teeth are suspected of following an incorrect We then performed a 3-dimensional imaging with
eruption pathway, preventive approaches to reestablish cone-beam computed tomography (CBCT), which high-
the physiological eruption process are considered, thus lighted the correct eruption pathways of permanent
decreasing the risk of canine impaction or adjacent right canines, whereas the maxillary left canine remained
root resorption of permanent teeth. palatally impacted, close to the root of the adjacent

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al 275

Fig 3. Initial orthogonal lateral cephalometric radiograph, cephalometric tracing, and panoramic radio-
graph.

lateral incisor that did not present signs of resorption PHASE 2 TREATMENT ALTERNATIVES
(Fig 5, B). The mandibular left canine was severely Various treatment modalities are available for the
transmigrated, lingually positioned, and covered resolution of the clinical situation of the mandibular
by cortical bone, with its crown in an intimate transmigrated canines. These include surgical extrac-
relationship with the roots of mandibular left incisors tion, autotransplantation, observation, and surgical
(Figs 5, C and D). exposure, followed by orthodontic repositioning.5
The advanced phase of permanent dentition and the A surgical extraction is the most frequently
need for early intervention because of the worsening of described option in the literature, especially in pa-
clinical conditions suggested the need to proceed with tients with severe inferior lack of space.13 In our pa-
phase 2 of the therapy to achieve a better bite, correct tient, we gained the needed space with a mild
management of spaces, provide anchorage for surgical proclination of the mandibular incisors and by taking
disimpaction and to allow for orthodontic repositioning advantage of the leeway space. Therefore, we could
of the left canines. consider alternatives to surgery because of the risks
associated with such a procedure. In addition, it
PHASE 2 TREATMENT OBJECTIVES would have involved a high degree of complexity
Treatment objectives for phase 2 were as follows: because of the lingual position of the canine. Simi-
(1) to gain correct spaces for the traction of the larly, we decided not to proceed with transalveolar
impacted canines, (2) to provide anchorage for surgical transplantation20 because of its complexity and the
disimpaction and to allow the orthodontic repositioning potential long-term risks associated with this proced-
of the left canines, (3) to establish a correct Class I dental ure.21
relationship, (4) to correct the excessive overbite, (6) to To avoid further worsening the clinical situation,
improve facial esthetics, and (7) to maintain occlusal including root resorption of mandibular incisors because
stability. of the mandibular left canine’s crown, the option of

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
276 Scribante et al

Table. Cephalometric measurements

Measurement Norm (mean 6 SD) Pretreatment Posttreatment
Skeletal pattern
SNA ( ) 82.0 6 2.0 80.9 84.2
SNB ( ) 80.0 6 2.0 75.8 81.9
ANB ( ) 2.0 6 2.0 5.1 2.3
Wits (mm) 0.0 6 2.0 0.7 1.4
SN-GoGn ( ) 32.0 6 5.0 30.5 23.5
PP-GoGn ( ) 20.0 6 5.0 17.4 15.1
Ar-Go-N ( ) 50.0 6 2.0 49.6 49.8
N-Go-Gn ( ) 70.0 6 3.0 67.2 66.7
Dental pattern
Interincisal angle ( ) 130.0 6 5.0 145.4 127.2
U1-PP ( ) 110.0 6 2.0 102.7 117.2
IMPA ( ) 93.0 6 1.0 94.6 100.5
Profile
Nasolabial angle ( ) 102.0 6 8.0 121.2 107.3
Facial angle ( ) 165.0 6 5.0 158.7 158.8
Upper lip (mm) - E plane 3.2 6 2.0 2.0 5.8
Lower lip (mm) - E plane 3.0 6 2.0 2.2 5.3
SD, standard deviation.

leaving the tooth in its ectopic position was abandoned, After gaining additional space, the surgical disimpac-
and the option of orthodontic repositioning was taken tion of the maxillary left canine could be executed. We
into consideration.11 applied a transpalatal bar to provide more anchorage.
This was followed by cantilever mechanics using a
PHASE 2 TREATMENT PROGRESS 0.017 3 0.025-in beta-titanium archwire (3M Unitek)
The patient’s treatment was discussed with the pa- placed inside the auxiliary tube of the first molar. The or-
tient’s parents explaining the complexity and length- thodontic repositioning for the maxillary left canine was
ening of therapy, and informed consent was obtained. successful.
Because the patient had to undergo 2 surgical expo- During his orthodontics treatment, the patient was
sures for the orthodontic repositioning procedures for diagnosed with spina bifida occulta, a neural tube
the left canines, orthodontic therapy initially started in defect.22 This further complicated his treatment course
the maxillary arch. as he could no longer attend his regular appointments,
The fixed appliance consisted of stainless steel resulting in the treatment duration lengthening. The pa-
brackets, buccal convertible triple tubes on maxillary tient underwent surgical interventions for his spina bi-
first molar bands, buccal convertible double tubes on fida occulta, followed by physical therapy for leg
mandibular first molar bands, and nonconvertible single mobilization: the orthodontic treatment was interrup-
tubes with a distal notch on maxillary and mandibular ted, but the appliance remained in place.
second molars bands (3M Unitek, Monrovia, Calif). The patient was reexamined 4 months after his last
To place the mandibular fixed appliance, we bonded appointment: the surgical exposure of the mandibular
bite raisings on the palatal surface of the maxillary left canine was operated by an oral surgeon through a
central incisors. This was possible thanks to anterior mucoperiosteal flap, with a paramarginal initial incision.
retro-incisal mini molds for deep bites (Ormco Europe, After the ostectomy of the lingual cortical bone, a direct
Amersfoort, BR, The Netherlands) that correctly posi- button was bonded (3M Unitek), and an orthodontic
tioned the brackets without occlusal interferences and traction chain 0.012-in (Leone, Florence, Italy) with
the early leveling of the inferior curve of Spee. traction eyelets was placed. The button was positioned
Fixed orthodontic treatment was managed with the as close as possible to the canine’s coronal tip (Fig 6,
MBT technique up to the last maxillary 0.019 3 A), the flap was sutured, providing a complete covering
0.025-in stainless steel archwire and mandibular 0.018 of the canine, and the metal ligature was connected,
3 0.025-in stainless steel archwire (3M Unitek). Open without traction, to the bracket of the left first premolar.
coil nickel-titanium springs (3M Unitek) were inserted Sutures were removed after 7 days, and the elastic
to create space for the maxillary and mandibular left ca- traction was applied with an elastic cotton thread
nines and mandibular right canines. (Leone), adopting the double-arch technique for the

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al 277

Fig 4. Linear dimensions of sella turcica.6-9 The patient presented an interclinoid distance (0.9 cm) that
was less than three-quarters of the TS-PS (1.35 cm), suggesting a partial calcification of the interclinoid
ligament and confirming the unfavorable pathway of eruption for the permanent canines.

Fig 5. Radiographic findings: A, Periapical radiograph of mandibular canines revealing a worsening in

the eruption pathway of the permanent mandibular left canine resulting in a horizontal inclination; B,
Transverse section of the maxillary arch. The maxillary left canine remained palatally impacted, close
to the root of the adjacent lateral incisor that did not present signs of resorption; C, Coronal anteropos-
terior section. The mandibular left canine was severely transmigrated, lingually positioned, and covered
by cortical bone; D, Transverse section of the mandibular arch showing the intimate relationship be-
tween mandibular left canine and the roots of mandibular left incisors.

orthodontic traction.23 To perform this technique, a During this stage of therapy, space augmentation for
0.018-in Special Hard Drawn stainless steel Australian the mandibular left canine was progressively produced,
auxiliary arch (AJ Wilcock Pty Ltd, Hay Mills, Birming- and the elastic traction was renewed every 2 weeks.
ham, United Kingdom) was added, with a loop that al- However, given the patient’s state of health, the patient
lowed the passage of the elastic traction through it, was unable to keep all his appointments, and therefore
positioned occlusally to the 0.018 3 0.025-in stainless the elastic traction was occasionally renewed less
steel archwire and in the space between the mandibular frequently than every 2 weeks (Fig 6, E).
lateral incisor and the first premolar but closer to the first Afterward, a bracket was positioned, finalizing and
premolar (Figs 6, B and 7). The loop’s distal position for completing the case through a normal sequence of arch-
the initial phase of traction aimed to limit the risk of root wires. We bonded the canine’s bracket without changing
resorption of mandibular incisors. After a radiographic the MBT prescription, keeping a torque value of 6 .
evaluation (Fig 6, C), the button was repositioned in a Because the impacted canine tipped buccally, this
more coronal position, and the auxiliary arch was rede- bracket prescription effectively generated lingual crown
signed with the loop positioned at the center of the torque and buccal root movement with a 0.019 3
space obtained for the mandibular left canine (Fig 6, D). 0.025-in nickel-titanium archwire. In a later stage, a

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
278 Scribante et al

Fig 6. Canine surgical exposure and orthodontic traction: A, surgical exposure and bonded button on
the mandibular left canine; B, Starting of orthodontic traction; C, Periapical radiograph suggesting the
need for the rebonding of the button in a more coronal position; D, Orthodontic traction after the rebond-
ing of the button; E, Stages of movement; F, Mandibular left canine present in the mandibular arch and
with its bracket.

0.019 3 0.025-in beta-titanium archwire was used, with and mandibular incisors (Fig 10). The cephalometric
an additional torque bend (Fig 6, F). The canine was re- analysis highlighted the achievement of a skeletal Class
positioned correctly, but a slight buccal tipping of the I (ANB, 2.3 ) and approximately correct divergence
crown remained; it was decided to avoid its further values (SN-GoGn, 23.5 ; PP-GoGn, 15.1 ). The deep
correction because it would have prolonged the therapy. overbite was corrected successfully; inevitably, an
The finishing phase was performed with maxillary acceptable proclination of maxillary and mandibular in-
and mandibular 0.019 3 0.025-in multibraided stainless cisors was obtained (U1-PP, 117.2 ; IMPA, 100.2 ) (Fig
steel archwires (3M Unitek). 11).
To avoid relapses, a maxillary clear plastic retainer
TREATMENT RESULTS fabricated with a 1 mm thick sheet was given to the pa-
The orthodontic repositioning of the left canines was tient, whereas a splint with a 0.8 mm steel wire (Rema-
successful. At the end of the treatment, we obtained nium lingual retainer; Dentaurum, Ispringen, Germany)
optimal arches alignment with good alignment of the was placed and bonded only on the lingual surfaces of
curve of Spee and the achievement of molar and canine mandibular canines.
Class I relationship (Figs 8 and 9). The patient’s parents decided to postpone the restor-
Spaces distal to maxillary canines and lateral incisors ative reconstructions for the small-sized maxillary lateral
were due to a discrepancy in the Bolton analysis. Lateral incisors.
incisors and second premolars in the maxillary arch were The entire orthodontic treatment lasted 38 months
small-sized. and was highly influenced by the state of the general
As already mentioned, the lingual root torque for the health of the patient. Because of the patient’s need for
mandibular left canine was not completely corrected. surgical interventions with subsequent periods of phys-
The occlusal view showed the absence of gingival reces- ical therapy, his compliance was inevitably low.
sion right after debonding; however, a gingival recession
could appear in long-term follow-up appointments. DISCUSSION
Esthetic analysis showed an improvement in facial Our patient presented for the first time in the later
profile and the achievement of a correct smile arc (Fig 8). mixed dentition stage, with the persistence of deciduous
Radiographic evaluation revealed good radicular canines. The permanent canines were impacted, as the
parallelism and no sign of root resorption of maxillary pretreatment panoramic radiograph shows. In complex

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al 279

evidence of partial calcification, and therefore an early

diagnosis could have been considered thanks to the
analysis of the shape of the sella turcica.
Regarding the possible role of malocclusions in the
transmigration of the mandibular canine, some
authors27 found that factors like Class II dental pattern
with a deep overbite, deep curve of Spee, excess tooth
material, and increased lower anterior facial height
may be predisposing factors. We found a Class II dental
pattern with a deep overbite and a slightly increased
lower anterior facial height in our patient. Others have
Fig 7. Schematic illustration of the double-arch tech-
found that a Class I dental pattern was more frequent
nique: the elastic traction (red), the round Australian arch-
in canine transmigration.28
wire 0.018-in (green), the stainless steel archwire 0.018 3
0.025-in (blue), and the open coil nickel-titanium springs To compare similar clinical patients and decide the
(yellow). best approach to the problem, we used the 5-type Mup-
parapu classification29 to classify the various positions
that transmigrated canines can assume: our patient cor-
patients, such as ours, early diagnosis could prevent the responds to type 1 in the Mupparapu classification. The
worsening of the clinical situation because the teeth can mandibular left canine was mesioangular positioned
be intercepted in a better position for orthodontic repo- across the midline within the jaw bone, lingually to ante-
sitioning, although it involves time-consuming rior teeth, and with its crown portion that crosses the
procedures.24 We used cervical headgear to correct the midline. Several studies have found that Mupparapu’s
Class II relationship and improve maxillary canines’ type 1 was the most frequently diagnosed type among
inclination25,26: the right canine erupted in the canine transmigrations.28,30-32
following stages of therapy, whereas the left canine The spatial position of the canines and their probabil-
needed surgical exposure and orthodontic repositioning. ity to cross the midline can also be evaluated through the
The same scenario occurred in the mandibular arch. angle between the canine’s axial inclination and the
The mandibular left canine became severely transmi- midsagittal plane.20 If this angle ranges from 25 to
grated and underwent surgical exposure followed by or- 30 , the canine is displaced, but it does not cross the
thodontic repositioning, whereas the right canine was midline. The canine will cross the midline if the angle
able to erupt. The spontaneous eruption of the mandib- is from 50 to 90 . Finally, there is an overlapping
ular right canine was probably a result of the extraction area, within the range of 30 -50 , in which the canine
of both the corresponding deciduous tooth and the first can cross the midline or not. The pretreatment pano-
primary molar, in addition to a 1.5 mm mesial slice of the ramic radiograph (Fig 3, C) shows that this angle’s value
primary second molar: these procedures allowed for the was 13.41 for the mandibular right canine and 48.52
creation of more space and the removal of a potential for the left canine. The second value signaled possible
mechanical obstacle.3 transmigration. The periapical radiograph (Fig 5, A)
Among the various causes of transmigration,5,11 and the CBCT frontal section (Fig 5, B) executed after
retention of persistent deciduous canines occurred in 9 months confirmed the evolving pathway of the
both arches at a later stage of growth of our patient. mandibular left canine that crossed the midline toward
Moreover, smaller maxillary lateral incisors and inade- the contralateral side. CBCT is also more accurate in de-
quate space in the mandible were present; nevertheless, tecting root resorption of adjacent teeth.4,33 Following
the right canines erupted without specific interventions. the clinical rationale of Cavuoti et al,14 we preferred to
Although there was a mechanical reason for canine perform the 3-dimensional examination once, after the
retention in this patient, a genetic etiology could have beginning of the fixed orthodontic treatment, to
played a role considering that all the permanent canines monitor the development of the clinical situation. More-
were displaced in the pretreatment stage. As suggested over, lingual position and older age are risk factors for
in previous studies,6-9 variations of the anatomic shape the impacted canine transmigration.1
of sella turcica can be related to dental anomalies. Although there is an abundance of literature explain-
Indeed, Scribante et al8 found that partial calcifications ing detailed procedures for the orthodontic reposition-
were more related to dental anomalies, particularly ing of labial mandibular impacted or transmigrated
buccal and palatal impaction of maxillary canines, canines,14-18 there is a paucity of literature on patients
compared with total calcification. Our patient had addressing canine’s lingual position. Most articles

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
280 Scribante et al

Fig 8. Final facial and intraoral photographs.

report only on the prevalence of lingual positioning of directional eyelet that guides the traction force depend-
transmigrated canines: Karabas et al34 and Bertl et al35 ing on its position.
reported a prevalence of 8.6% and 8.5%, respectively, At first, the direction of the orthodontic force was
whereas Koç et al1 a prevalence as high as 51.4%. Only distal to limit the stress in that region and avoid the
1 article noted that they successfully treated a lingually risk of resorption of the roots of the adjacent teeth
oriented canine with the insertion of a temporary skel- because of the intimate position of the crown of the
etal anchorage device, but the steps of the orthodontic canine36; the incidence of this occurrence is estimated
treatment were missing.12 to be 7.3% and is more likely if the canine is lingually
We adopted the double-arch technique (Fig 7),23 so- impacted.35 Subsequently, the eyelet was moved more
called for using 2 archwires, for the orthodontic traction centrally on the alveolar process of the canine. Force
of the mandibular transmigrated canine. The stabiliza- traction did not exceed $60 g, as suggested in the liter-
tion archwire is a stainless steel rectangular wire inserted ature,37 and the repositioning was successful, with a
at first and ligated to the brackets, only to be removed slight lingual inclination of the tooth that was decided
after the canine’s eruption. Its purposes are anchorage, not to correct beyond to avoid the lengthening of the
maintenance of the space for the canine, and mainte- treatment. We evaluated using a cantilever for the trac-
nance of the arch form. The traction archwire is a round tion of the transmigrated canine, but the presence of an
Australian archwire 0.018-in, applied over the rectan- excessive overbite caused occlusal interferences. An
gular archwire and with a step-down bend in the space alternative could have been to bend the hole for the
for the canine’s eruption. The step-down bend is de- elastic thread directly on the rectangular wire instead
signed from the distal surface of the lateral incisor to of the 0.018-in auxiliary Australian wire. In our patient,
the mesial surface of the first premolar. It presents a the auxiliary arch allowed control of the force direction,

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al 281

Fig 9. Final study models.

whereas the stabilization arch maintained the arch form procedures, more susceptibility to dental caries, poor
during traction. Light forces were applied to the traction oral hygiene, and a latex allergy prevalence of 28%-
to control the proclination of the mandibular incisors. 67%.40 Given the findings related to sella turcica that
The lack of a stronger anchorage inevitably caused were observed on the lateral cephalometric radiograph,
the proclination of mandibular incisors; appliances for a diagnosis of spina bifida could have been made before
the reinforcement of the anchorage, such as the lingual the orthodontic treatment. Indeed, the detection of sella
arch22,38 and the lip bumper,39 have been proposed, but bridging is expressly related to myelomeningocele, the
the former could not be applied because of the presence most common and severe form of spina bifida occulta.22
of the transmigrated canine, whereas the latter could An early diagnosis could have modified the treatment
have reduced the already low compliance of the patient, approach and changed the therapy duration: the
which was the reason why the possibility of inserting a surgical intervention and the pathology inevitably
temporary skeletal anchorage device, as done by Sinko lengthened the orthodontic treatment, already in itself
et al,12 was excluded. Herein, miniscrews were used as long-lasting and complex. Compliance was inevitably
support for the orthodontic treatment, successfully re- affected, which in turn affected the orthodontic treat-
positioning the transmigrated canine in 3 out of 4 pa- ment. Proper oral hygiene was hard to achieve, and
tients. Better results may have been obtained if the cooperation with orthodontic elastics was very low.
patient were treated with a skeletal anchorage provided Further complicating the situation, the patient had dif-
by the insertion of a miniscrew. However, we preferred to ficulty sitting in the dental chair after his surgical inter-
adopt conventional mechanics to avoid adding a second ventions. The other complications related to spina bifida
step of oral surgery. did not occur in our patient, likely because of a milder
The patient suffered from spina bifida occulta, a type of disease in his case.
neural tube defect in which there is a failure of neural
tube closure during the first month in utero. This spina
bifida is characterized by no herniation of central ner- SUMMARY AND CONCLUSIONS
vous system contents, rare symptoms, and complica- Lingual transmigration of mandibular canines is an
tions, and is usually found incidentally.22 There are uncommon occurrence that clinicians should be ready
several implications of this diagnosis in dentistry: diffi- to address when patients present to their clinic. Early
culties in sitting in the dental chair, limited jaw opening, diagnosis and intervention in patients with an anoma-
a higher risk of infective endocarditis during invasive lous eruption pathway of permanent canines can be

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
282 Scribante et al

Fig 10. Final orthogonal lateral cephalometric radiograph, cephalometric tracing, and panoramic
radiograph.

Fig 11. Cephalometric superimpositions between initial (black) and final (red) tracings.

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Scribante et al 283

decisive. Conventional mechanics for the orthodontic re- 15. Trivedi B, Jayam C, Bandlapalli A, Patel N. Surgical and
positioning of lingually transmigrated mandibular ca- orthodontic management of a horizontally impacted permanent
mandibular canine: timing is vital. BMJ Case Rep 2014;
nines can result in successful outcomes without
2014:bcr2014205052.
significant complications, even though it can be chal- 16. Vera-Guerra JA, Herrera-Atoche JR, Colome-Ruiz GE. Orthodontic
lenging and time-consuming. treatment of bilateral impacted mandibular canines and a
Mupparapu type 2 transmigration. Case Rep Dent 2019;2019:
ACKNOWLEDGMENTS 7638959.
17. Kılıç N, Oktay H. Orthodontic intervention to impacted
The authors would like to thank Filiberto Cricr
ı (Cair- and transposed lower canines. Case Rep Dent 2017;2017:
oli College) for the free-hand drawing of Figure 7. 4105713.
18. Crescini A, Baccetti T, Rotundo R, Mancini EA, Prato GP. Tunnel
technique for the treatment of impacted mandibular canines. Int
SUPPLEMENTARY DATA
J Periodontics Restorative Dent 2009;29:213-8.
Supplementary data associated with this article can 19. Alessandri Bonetti G, Zanarini M, Incerti Parenti S, Marini I,
be found, in the online version, at https://doi.org/10. Gatto MR. Preventive treatment of ectopically erupting maxillary
permanent canines by extraction of deciduous canines and first
1016/j.ajodo.2021.09.022.
molars: a randomized clinical trial. Am J Orthod Dentofacial Or-
thop 2011;139:316-23.
REFERENCES 20. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;
3:117-21.
1. Koç A, Kaya S, Abdulsalam WA. Three-dimensional analysis of 21. Gonnissen H, Politis C, Schepers S, Lambrichts I, Vrielinck L, Sun Y,
impacted maxillary and mandibular canines and evaluation of fac- et al. Long-term success and survival rates of autogenously trans-
tors associated With transmigration on cone-beam computed to- planted canines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
mography images. J Oral Maxillofac Surg 2021;79: 538.e1-538.e11. 2010;110:570-8.
2. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral 22. Garg A, Revankar AV. Spina bifida and dental care: key clinical is-
Surg 1985;14:547-9. sues. J Calif Dent Assoc 2012;40:861-5,868-9.
3. Joshi MR. Transmigrant mandibular canines: a record of 28 cases 23. Crescini A, Pini Prato GP. [Combined treatment of the impacted
and a retrospective review of the literature. Angle Orthod 2001;71: canine: the double arch technic]. Dent Cadmos 1988;
12-22. 56:19,21-6,29-36 passim. Italian.
4. Vuchkova J, Farah CS. Canine transmigration: comprehensive 24. Celikoglu M, Kamak H, Oktay H. Investigation of transmigrated
literature review and report of 4 new Australian cases. Oral Surg and impacted maxillary and mandibular canine teeth in an ortho-
Oral Med Oral Pathol Oral Radiol Endod 2010;109:e46-53. dontic patient population. J Oral Maxillofac Surg 2010;68:
5. Dalessandri D, Parrini S, Rubiano R, Gallone D, Migliorati M. 1001-6.
Impacted and transmigrant mandibular canines incidence, aeti- 25. Hadler-Olsen S, Pirttiniemi P, Kerosuo H, Sj€ogren A, Pesonen P,
ology, and treatment: a systematic review. Eur J Orthod 2017; Julku J, et al. Does headgear treatment in young children
39:161-9. affect the maxillary canine eruption path? Eur J Orthod 2018;
6. Leonardi R, Barbato E, Vichi M, Caltabiano M. A sella turcica bridge 40:583-91.
in subjects with dental anomalies. Eur J Orthod 2006;28:580-5. 26. Armi P, Cozza P, Baccetti T. Effect of RME and headgear treatment
7. Leonardi R, Farella M, Cobourne MT. An association between sella on the eruption of palatally displaced canines: a randomized clin-
turcica bridging and dental transposition. Eur J Orthod 2011;33: ical study. Angle Orthod 2011;81:370-4.
461-5. 27. Holla A, Saify M, Parashar S. Transmigration of impacted mandib-
8. Scribante A, Sfondrini MF, Cassani M, Fraticelli D, Beccari S, ular canines and its association with malocclusion and
Gandini P. Sella turcica bridging and dental anomalies: is there morphology: an analysis of seven cases. Orthodontics (Chic.)
an association? Int J Paediatr Dent 2017;27:568-73. 2012;13:156-65.
9. Ali B, Shaikh A, Fida M. Association between sella turcica bridging 28. Plakwicz P, Abramczyk J, Wojtaszek-Lis J, Sajkowska J, Warych B,
and palatal canine impaction. Am J Orthod Dentofac Orthop 2014; Gawron K, et al. The retrospective study of 93 patients with trans-
146:437-41. migration of mandibular canine and a comparative analysis with a
10. Buyukkurt MC, Aras MH, Caglaroglu M, Gungormus M. Transmi- control group. Eur J Orthod 2019;41:390-6.
grant mandibular canines. J Oral Maxillofac Surg 2007;65:2025-9. 29. Mupparapu M. Patterns of intra-osseous transmigration and
11. Aras MH, Halicioglu K, Yavuz MS, Ça glaro
glu M. Evaluation of ectopic eruption of mandibular canines: review of literature and
surgical-orthodontic treatments on impacted mandibular canines. report of nine additional cases. Dentomaxillofac Radiol 2002;31:
Med Oral Patol Oral Cir Bucal 2011;16:e925-8. 355-60.
12. Sinko K, Nemec S, Seemann R, Eder-Czembirek C. Clinical man- 30. Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and
agement of impacted and transmigrated lower canines. J Oral transmigration in a patient population. Dentomaxillofac Radiol
Maxillofac Surg 2016;74:2142.e1-2142.e16. 2004;33:164-9.
13. Camilleri S, Scerri E. Transmigration of mandibular canines—a re- 31. Azeem M, Afzal A, Ahmed Z, Ali MM, Haq AU, Hamid WU. Inves-
view of the literature and a report of five cases. Angle Orthod 2003; tigation of transmigrated mandibular canines. Dental Press J Or-
73:753-62. thod 2019;24:65-8.
14. Cavuoti S, Matarese G, Isola G, Abdolreza J, Femiano F, Perillo L. 32. Bhullar MK, Aggarwal I, Verma R, Uppal AS. Mandibular canine
Combined orthodontic-surgical management of a transmigrated transmigration: report of three cases and literature review. J Int
mandibular canine. Angle Orthod 2016;86:681-91. Soc Prev Community Dent 2017;7:8-14.

American Journal of Orthodontics and Dentofacial Orthopedics February 2023  Vol 163  Issue 2
284 Scribante et al

33. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption of 37. Bishara SE. Impacted maxillary canines: a review. Am J Orthod
maxillary canines: a CT study. Angle Orthod 2000;70:415-23. Dentofacial Orthop 1992;101:159-71.
34. Cakir Karabas H, Ozcan I, Erturk AF, Guray B, Unsal G, Senel SN. 38. Dinoi MT, Marchetti E, Garagiola U, Caruso S, Mummolo S,
Cone-beam computed tomography evaluation of impacted and Marzo G. Orthodontic treatment of an unerupted mandibular
transmigrated mandibular canines: a retrospective study. Oral Ra- canine tooth in a patient with mixed dentition: a case report. J
diol 2021;37:403-11. Med Case Rep 2016;10:170.
35. Bertl MH, Frey C, Bertl K, Giannis K, Gahleitner A, Strbac GD. 39. Agarwal S, Yadav S, Shah NV, Valiathan A, Uribe F, Nanda R.
Impacted and transmigrated mandibular canines: an analysis of Correction of bilateral impacted mandibular canines with a lip
3D radiographic imaging data. Clin Oral Investig 2018;22: bumper for anchorage reinforcement. Am J Orthod Dentofacial Or-
2389-99. thop 2013;143:393-403.
36. Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal and peri- 40. Garg A, Utreja A, Singh SP, Angurana SK. Neural tube defects and
odontal reactions to orthodontic alignment of palatally impacted their significance in clinical dentistry: a mini review. J Investig Clin
canines. Angle Orthod 1994;64:257-64. Dent 2013;4:3-8.

February 2023  Vol 163  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics