ORIGINAL ARTICLE

Local factors relating to mandibular

canine impaction: A retrospective study

,a Giulia Sottile,b Ersilia Barbato,a and Michele Cassettaa
Rosanna Guarnieri,a Francesca Germano
Rome, Italy

Introduction: This study aimed to investigate the characteristics of impacted and transmigrated mandibular ca-
nines and the association existing between them and some local factors, such as degrees of axial inclination of
mandibular incisors, skeletal Class, and mandibular symphysis width. Methods: A retrospective observational
study was performed on the medical records and radiographic examination (panoramic radiographs and lateral
cephalograms) of 102 orthodontic patients divided into a study group, with at least 1 impacted mandibular canine
(51 subjects) and a control group, without mandibular impaction (51 subjects). A chi-square test, t test, and
analysis of variance test analysis were used to analyze the data. Results: Unilateral and buccal impaction
and the presence of the deciduous canine were the more prevalent characteristics of impacted canines, whereas
39.2% presented transmigration. Furthermore, the persistence of the deciduous canine on the impaction
side (P \0.0001) and the mesial axial inclination of the impacted canine (P \0.0001) were found to be statisti-
cally significant characteristics. A statistically significant association was found between the impaction of the
mandibular canine and mandibular incisor to the mandibular plane angle (IMPA) (IMPA, 95.8
; P 5 0.009).
An additional statistically significant association was found with transmigrated canines (IMPA, 96.8
; P 5
0.024). Conclusions: The mesialization of the canine cusp and the persistence of the mandibular deciduous
canine are characteristics frequently found in the impaction of the mandibular canine. An accentuated vestibular
inclination of the mandibular incisors is significantly associated with mandibular canine impaction. (Am J Orthod
Dentofacial Orthop 2024;165:556-64)

A
tooth is defined as impacted when it has ex- in reference to mandibular canines. Although most of
hausted its eruptive thrust and remains within the studies on transmigration concern mandibular ca-
the bone structure without making its appear- nines, there are also instances reported in the literature
ance in the arch during the physiological eruption of the transmigration of maxillary canines, mandibular
time. It has a closed root apex with an inactive peri- lateral incisors, and premolars. 8-11
odontal ligament.1 The term retention, instead, refers Permanent maxillary canine impaction appears to be
to an intraosseous tooth that still has an immature one of the most frequently reported dental anomalies in
apex and the possibility of finishing its eruptive course the literature;12 however, only a few studies exist con-
that it could not complete in the physiological period cerning the impaction of the mandibular canine.13 This
because of an obstacle or impediment.2 An impacted phenomenon occurs most frequently in the maxilla,
or retained tooth rarely migrates away from the site in with a reported prevalence ranging 0.97%-
which it developed; however, if it does, it usually remains 7.10%6,14-19 compared with the mandibular site, which
on the same side of the dental arch.3 When the tooth has a prevalence between 0.3% and 2.8%.20-23
crosses the midline, this phenomenon is known as trans- Furthermore, the prevalence rate of transmigration
migration.4-6 The term was first used by Ando et al,7 ranges 0.10%-0.31%.24
a
Department of Oral and Maxillofacial Sciences, School of Dentistry, Sapienza There is no consensus in the current literature on the
University of Rome, Rome, Italy. distribution and prevalence of a particular gender asso-
b
Private practice, Rome, Italy.
ciated with mandibular canine impaction. In some
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. studies, it was found to be more prevalent in females
Address correspondence to: Rosanna Guarnieri, Department of Oral and Maxil- (F) (1.00 F to 0.35 male [M])25 in others, such as those
lofacial Sciences, School of Dentistry, Sapienza University of Rome, Via Caserta
of Aydin et al6 (1.00 M to 0.33 F) and Buyukkurt
6, 00161 Rome, Italy; e-mail, rosanna.guarnieri@uniroma1.it.
Submitted, May 2023; revised and accepted, November 2023. et al26 (1.00 M to 0.67 F), it was found to be more com-
0889-5406 mon in M. It has been reported that the impaction of the
Ó 2024 by the American Association of Orthodontists. This is an open access
mandibular canines predominantly affects the buccal
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.ajodo.2023.11.013 site and the right side of the mandible.6

556
Guarnieri et al 557

Many general and local etiologic factors could cause findings (panoramic radiographs and lateral cephalo-
impaction, altering the normal process of formation and gram) of patients treated at the Orthodontic Unit of the
eruption of the canine or deviating the tooth from its Department of Odontostomatological and Maxillofacial
normal eruptive course. They are classified into general Sciences, Sapienza - University of Rome, Italy.
and local factors, and sometimes, several causes can A total of 2507 medical records were analyzed (ie,
occur in combination to determine the pathology.27,28 those of all patients who were being treated within the
Although there are several theories in the literature Orthodontics Unit in 2022). The analysis of the pretreat-
about the etiology of mandibular canine impaction, ment records of 2507 white patients was performed after
and a genetic hypothesis has been formulated,29 local the approval of the regional ethical review board of the
factors are believed to be the main cause.5,13,29-31 “Umberto I” General Hospital of Rome (Rif. 3755).
Particularly, it has been suggested that the greater Criteria for inclusion in the study sample were com-
cross-sectional area of the anterior mandible compared plete anamnestic information (concerning the subject’s
with that of the maxilla,6 excessive proclination of the generalities, medical history, and orthodontic and dental
mandibular incisor,32 increased axial inclination, treatment), with a good quality panoramic radiograph
widening of the symphysis cross-section,31 and skeletal and lateral cephalogram.
Class II malocclusion, in particular with retroclined Exclusion criteria were the presence of craniofacial
maxillary incisors,33 which may offer favorable condi- anomalies or syndromes, systemic pathologies, ongoing
tions for mandibular canine impaction. radiotherapy or chemotherapy, head and neck surgery,
Impacted mandibular canines usually remain and previous surgical-orthodontic procedures. Subjects
impacted and asymptomatic; however, they can erupt with radiographs that could not be clearly analyzed
ectopically on the same side or the opposite side of the were likewise not included.
arch, crossing the midline.34 They may cause the resorp- The study group (SG) was represented by subjects
tion of roots or the tilting of adjacent teeth35 and neuro- with at least 1 mandibular-impacted canine without
logic symptoms,36 thus causing pain and discomfort to preference for depth, position, inclination, or location.
the patient. In addition to these mechanical complica- The diagnosis was made on the basis of the clinical ex-
tions, phlogistic or dysplastic complications may occur, amination and available radiographic examinations
such as follicular cysts and odontogenic neoformations, (including 3-dimensional [3D] options in which avail-
which may also be the effective cause of impaction.22 able). The definition developed by Joshi et al5 was
Regarding the transmigration of the mandibular used to diagnose transmigration, which assesses the ten-
canine (TMC), the etiology is still unknown; one of the dency of the canine to cross the midline.
theories is related to atypical lamina tissue drift and Of the 2507 subjects analyzed, 60 exhibited impac-
displacement of the tooth bud during the embryogenesis tion of at least 1 of the 2 mandibular canines. Of these,
phase.37,38 5 subjects were excluded because they did not have a
Although there are several possible etiologic factors lateral cephalogram, $3 more subjects were eliminated
associated with responsible tooth impaction, this study because they did not have a clear panoramic radiograph,
focused only on some possible dentoskeletal factors, 1 subject with a craniofacial syndrome, and a further
easily noticeable by basic radiographic examinations subject who had undergone maxillofacial surgery were
such as panoramic radiographs and lateral cephalo- also excluded.
grams, with the aim of evaluating a possible association After this analysis, 51 subjects with at least 1
that could be useful for the early interception of possible impacted mandibular canine who met the inclusion
risk situations of mandibular canines impaction. criteria were selected as SG.
This retrospective, observational study of panoramic The control group (CG) consisted of an equal number
radiographs and lateral cephalograms aimed to investigate of patients from the Orthodontic Unit who did not have
characteristics of impacted mandibular canines and TMC a mandibular canine impact, who showed similar char-
and assess whether an increased proclination of the acteristics in terms of age and presented complete
mandibular incisors, the presence of a skeletal Class II rela- medical records in the anamnestic information section
tionship and a wide symphysis are more frequently associ- and whose clear and traceable radiographs were avail-
ated with impaction of the canine in the mandibular arch. able.
Two orthodontists (R.G. and F.G.) collected all the
data and separately examined panoramic radiographs
MATERIAL AND METHODS and lateral cephalograms on the subjects of both groups.
A retrospective, observational study was performed on The data recorded included: (1) The subject’s
the basis of information from clinical and radiographic personal and medical history—gender, age, systemic

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558 Guarnieri et al

diseases, allergies, surgery, and trauma; (2) clinical and Statistical analysis
radiographic information—impaction and transmigra- Statistical analyses were conducted with the SPSS pro-
tion of mandibular canines, impaction side (right, left), gram (version 25.0: IBM, Armonk, NY). The sample size
the persistence of deciduous canine (presence or was established after a power analysis was performed
absence), cusp inclination of impacted canine (mesial, with the G*Power (version 3.1.9.7; Franz Faul, Universit€at
distal, or vertical, horizontal), impaction site (buccal, Kiel, Kiel, Germany),43 which showed that the minimum
lingual, or in crest), skeletal classification (ANB), incisor number of subjects to be included in the analysis was
mandibular plane angle (IMPA), and width (W) of 88 (power 5 0.80; a 5 0.05; effect size 5 0.30).
mandibular symphysis (narrow, normal, or wide). To verify the reliability of the radiographic analysis
The impaction and transmigration of mandibular ca- and data collected by the 2 operators (R.G. and F.G.),
nines, impaction side, the persistence of the deciduous all measurements were subjected to 2 separate random
canine, and the cusp inclination of the impacted canine evaluations in 2 different periods. Cohen’s k statistic
using the method by Bertl et al,22 were evaluated on was conducted; the test result, on all measures consid-
panoramic radiographs (Fig 1). The impaction site, skel- ered, showed substantial interexaminer agreement be-
etal Class, vestibular inclination of mandibular incisors, tween the 2 operators (a 5 80).
and symphysis anatomy were evaluated on lateral ceph- In addition, the same statistic was also used to assess
alograms (Fig 2). intraoperator agreement 3 weeks after the first observa-
All data were subsequently entered into Microsoft tions (k .0.80).
Excel (Microsoft Corp, Redmond, Tex). All panoramic The relative frequencies and, when possible, descrip-
and lateral cephalograms were acquired as jpg files. The tive statistics (mean 6 standard deviation) were
panoramic radiographs were analyzed using a RadiAnt calculated for all the variables under consideration.
DICOM viewer (Medixant, Poznan, Poland) software. The chi-square and Fisher exact tests were used to assess
On the lateral cephalogram, a cephalometric analysis possible associations between the impaction of mandib-
was performed according to McLaughlin’s method39 us- ular canines and the variables considered.
ing the Dolphin Imaging software (Dolphin Imaging and This analysis was carried out both on the SG alone
Management Solutions, Chatsworth, Calif). and in a comparison between SG and CG.
The skeletal Class was calculated in the cephalometric T tests for independent samples and analysis of vari-
analysis on the basis of the angle ANB, formed by the ance were used to investigate the presence of significant
intersection at point N (nasion) of the straight lines pass- differences in mean IMPA scores between the SG and CG
ing through points A (maxillary) and B (mandibular): (Student t test) and between subjects with transmigrated
Class I: 2
-4
; Class II: .4
; and Class III: \2
or nontransmigrated and CG (analysis of variance),
Tweed measurements were used to evaluate the respectively. The results were considered significant at
sagittal variations of the incisor in the mandible.40 a probability P \0.05.
The value of IMPA is given by the angle between the
long axis of the most protruding mandibular incisor and
RESULTS
the base of the mandible (line joining the point [Me] and
the “lower portion on the back of the mandible base”). The study was carried out on a total of 102 subjects,
The normal value of inclination of the mandibular inci- 51 M (50.0%) and 51 F (50.0%), of whom 51 (50.0%)
sors in relation to the mandible of the white ethnic group were in the SG and 51 (50.0%) in the CG. Specifically,
is 90
6 5
. in the SG, there were 28 M (54.9%) and 23 F (45.1%),
The anatomy of the symphysis was classified accord- whereas in the CG, there were 23 M (45.1%) and 28 F
ing to the study by G€ utermann et al41 and Mazurova (54.9%).
42
et al. The W of the symphysis was calculated as the dis- The mean age of the participants was 14.8 6 5.05
tance between the anterior and posterior line tangents to years: in the SG, the mean age was 14.7 6 5.12 years
the symphysis perpendicular to the mandibular plane (a (range, 10-33 years), whereas in the CG, the mean age
line tangent to the lower edge of the mandible) (Fig. 3). was 14.9 6 4.98 years (range, 10-31 years).
The anatomy of the symphysis was classified on the Of the 51 subjects in the SG, 56 impacted mandibular
basis of W as follows: (1) narrow symphysis: 14-15 canines were analyzed. Five subjects (9.8%) had bilateral
mm; (2) normal symphysis: 15-16 mm; and (3) wide impaction, and the remaining 46 (90.2%) were unilat-
symphysis: $16 mm. eral. The chi-square test showed this result to be

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Guarnieri et al 559

Fig 1. Using methods from Bertl et al,22 the angle subtended by the line passing through the mandib-
ular midline (red) and the line passing through the long axis of the mandibular canine (black)
were traced to classified cusp inclination. A, 0
Classified as vertical coronally directed angulation;
B, 90
As horizontal, mesially directed angulation; C, Negative values a distally directed angulation;
D, Between 0
and 90
mesial cusp angulation.

statistically significant (c2 5 23.143; P \0.0001), with was found. Results of the descriptive analysis of SG are
unilateral impaction more frequent than bilateral impac- synthesized in Table I.
tion. In the SG, 20 of 51 (39.2%) patients presented trans-
Twenty-nine mandibular canines (51.7%) exhibited migration. Nine of the 20 subjects (45.0%) were M and
left-sided impaction (tooth 3.3) and 27 (48.2%) right- 11 (55.0%) were F.
sided impaction (tooth 4.3). However, the frequency of In addition, of the 20 subjects, 11 (55.0%) had left-
distribution in relation to the side of impaction was sided impaction, and the remaining 9 (45.0%) had
not statistically significant (c2 5 0.071; P 5 0.789). right-sided impaction. This frequency distribution was
Forty-six of 56 mandibular canines (82.1%) had a not statistically significant (c2 5 3.700; P 5 0.157).
buccal impaction site; of the remaining canines, 9 Three subjects had bilateral impaction, consisting of
(16.1%) were impacted in the lingual site and 1 (1.8%) 1 transmigrated canine and 1 nontransmigrated canine.
in the crest. The chi-square test showed this result to The chi-square test showed that, even with transmi-
be statistically significant (c2 5 100.321; P \0.0001). grated canines, unilateral impaction is more frequent
Thus, a buccal site is more frequent in subjects with than bilateral impaction, and this distribution was statis-
mandibular canine impaction. tically significant (c2 5 9.800; P 5 0.002).
Among the 56 canines analyzed, 46 (82.1%) still had All transmigrated mandibular canines occurred in the
the deciduous canine in the arch. The chi-square test re- buccal site (c2 5 16.300; P \0.0001).
vealed that the presence of the deciduous canine in the The chi-square test showed a statistically significant
mandibular canine impaction side was statistically association (c2 5 12.800; P \0.0001) between TMC
significantly more frequent (c2 5 23.143; P \0.0001). and the presence of the respective deciduous canine.
Furthermore, 74.5% (38 of 51) of the subjects in the The persistence of the mandibular canine in the arch
SG presented the impacted canines with a mesial cusp was found in 18 subjects (90.0%).
inclination, 5.88% (3 of 51) were oriented distally, Concerning the cusp inclination of the transmigrated
11.8% (6 of 51) had a vertical position, and 7.8% (4 of canines, 16 subjects (80.0%) had a mesial angulation,
51) were horizontal. The chi-square test showed this and 4 (20.0%) had a horizontal angulation. No subjects
result to be statistically significant (c2 5 80.429; had a distal or vertical cusp angle. This difference in
P \0.0001). Thus, in subjects with mandibular canine frequency distribution was significant in the chi-square
impaction, mesioangulation of the cusp is more frequent test (c2 5 7.200; P 5 0.007), underlining the tendency
than in other orientations. In subjects with bilateral of transmigrated canines to have mesial cusp angula-
impaction, the same cusp angulation of the 2 elements tion.

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560 Guarnieri et al

Fig 2. The impaction site described on the basis of the inclination analyzed on the lateral cephalogram
and characteristics related to the case analyzed on panoramic radiographs. Patient 1: A, Panoramic
radiograph showing the transmigration of mandibular left canine; B, Lateral cephalogram showing a
buccal impaction. Patient 2: C, Panoramic radiograph showing an impaction of mandibular right canine
without the persistence of deciduous canine; D, Lateral cephalogram showing a crest impaction of
mandibular right canine. Patient 3: E, Panoramic radiograph showing an impaction of mandibular right
canine with the persistence of deciduous canine; F, Lateral cephalogram showing a lingual site impac-
tion of mandibular right canine.

Results for TMC are summarized in Table II. frequent in SG vs in CG: 43.1% (22 of 51) vs 49.0% (25
In terms of gender, the chi-square test found no sig- of 51), respectively. There were 3 subjects in SG (5.9%)
nificant differences in the distribution of M and F within and 6 in CG (11.7%) with a Class III relationship.
the 2 groups examined (28 M [54.9%] and 23 F [45.1%] No significant associations emerged between SG and
in the SG and 23 M [45.1%] and 28 F [54.9%] in the CG) symphysis anatomy (c2 5 4.943; P 5 0.084). Thus, sym-
(c2 5 0.980; P 5 0.428). physis morphology was similar between SG and CG. In
The results of the t test made it possible to observe the SG, there were 19 subjects (37.3%) with normal,
that the 2 groups considered had no significant differ- 16 with narrow (31.4%), and 16 with wide (31.4%) anat-
ences with regard to age (t 5 0.183; P 5 0.853). omy, whereas in CG, there were 27 subjects (52.9%) with
The results of the chi-square test showed that there is normal, 7 (13.7%) with narrow, and 17 (33.3%) with
no significant association between belonging to the SG wide anatomy.
and CG and skeletal Class (c2 5 1.974; P 5 0.373). How- There was no statistically significant association be-
ever, from the clinical point of view, the presence of sub- tween subjects with elevated IMPA and symphysis anat-
jects with a Class I relationship is more frequent in SG vs omy (F 5 0.740; P 5 0.392).
CG (26 of 51 [50.9%] vs 20 of 51 [39.2%], respectively). In Results comparing SG and CG are summarized in
contrast, subjects with a Class II relationship were less Table III.

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Guarnieri et al 561

Table I. Descriptive statistics within the SG and results

regarding characteristics of subjects and impacted
mandibular canines
Variables n (%) c2 P value
Impaction side
Unilateral 46 (90.2) 23.143 \0.0001
Bilateral 5 (9.8)
Right 27 (48.2) 0.071 0.789
Left 29 (51.7)
Impaction site
Buccal 46 (82.1) 100.321 \0.0001
Lingual 9 (16.1)
In crest 1 (1.8)
Deciduous canine
Presence 46 (82.1) 23.143 \0.0001
Absence 10 (17.8)
Cusp inclination
Fig 3. The W of the symphysis is calculated as the dis- Mesial 38 (74.5) 80.429 \0.0001
tance between the 2 lines tangents to the anterior and Distal 3 (5.9)
posterior point of the symphysis perpendicular to the Vertical 6 (11.8)
mandibular plane (a line tangent to the lower edge of Horizontal 4 (7.8)
the mandible). Note. There were 51 subjects and 56 impacted canines in SG. Data
were analyzed using the c2 test (Significance P \0.05).

The results of the t test revealed that the 2 groups had of the highest percentages found in the literature.13 The
significant differences in terms of the value of IMPA (t 5 prevalence of transmigration, 0.8%, is also in line with
2.656; P 5 0.009). The average IMPA in SG was 95.8
, that in previous studies.44
whereas it was 92.3
in the CG. The average IMPA in In previous studies, predominantly panoramic radio-
subjects with transmigrated mandibular canines was graphs were examined,17 with only a few recent studies
96.8
, which was higher than that in the rest of the sam- employing 3D computed tomography methods.22,45,46
ple and statistically significant (F 5 3.863; P 5 0.024). In this study, both panoramic radiographs and lateral
Analysis of variance and t tests (Table IV) were used cephalograms were evaluated.
to compare IMPA values in different groups. Considering the results of this study, the data from
the descriptive analysis of the sample revealed that there
DISCUSSION is no statistically significant gender difference in sub-
Impaction of the permanent mandibular canine is a jects with mandibular canine impaction and transmigra-
rare dental anomaly, with a few studies available in the tion. This result, in agreement with Azeem et al,44
literature. contrasts with studies that reported a M-to-F ratio of
This study analyzed one of the largest samples of 1 F to 0.33 M6 and 1 F to 0.67 M26 and with studies
mandibular canine impaction in the literature, with the that instead highlighted a prevalence of the F sex.3,47
aim of evaluating specific characteristics obtained from In contrast, the prevalence of the F sex regarding the
routine 2-dimensional radiographs (panoramic radio- impaction of the maxillary canine has been reported by
graphs and lateral cephalograms). Any associations most of the studies, a finding that points to a genetic
found could not only inform the clinician of possible origin of the anomaly.48
risk factors but also confirm or reject associations In this study, most mandibular-impacted canines
already investigated in the literature and give rise to occurred unilaterally without significant differences be-
further future studies. tween the right and left sides. Other studies have re-
Previously reported prevalence rates for impaction of ported that unilateral canines are more frequent than
the permanent mandibular canine ranged from 0.3%- bilateral ones.49 Recently, it was reported that mandib-
2.8%,20-22 whereas transmigration ranged from ular canines on the left side are more often impacted
0.10%-0.31%.23,24 This study found a prevalence of than those on the right.6,25
mandibular canine impaction of 2.4% in the orthodontic With regard to the impaction site, in this study, the
population under review. This result is within the range buccal site of impaction was the most common; this is

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562 Guarnieri et al

Table II. Descriptive statistics within the SG and re- Table IV. IMPA scores between the SG and CG (Stu-
sults regarding characteristics of subjects and transmi- dent t test) and between subjects with transmigrated
grated mandibular canines or nontransmigrated and CG (ANOVA)
Variables n (%) c2 P value Variables IMPA t or F P values
Impaction side Student t test
Unilateral 17 (85.0) 9.800 0.002 SG 95.8
6 7.858
2.656 0.009
Bilateral 3 (15.0) CG 92.3
6 5.323

Right 9 (45.0) 3.700 0.157 ANOVA
Left 11 (55.0) SG
Impaction site Impacted canine 95.2
6 6.993
3.863 0.024
Buccal 20 (100) 16.300 \0.0001 TMC 96.8
6 8.420

Lingual – CG 92.3
6 5.323

In crest –
ANOVA, analysis of variance.
Deciduous canine
Note: Values are mean 6 standard deviation. Statistical significance:
Presence 18 (90.0) 12.800 \0.0001
P \0.05.
Absence 2 (10.0)
Cusp inclination
Mesial 16 (80.0) 7.200 0.007 been put forward to explain this phenomenon.3 Early
Distal –
Vertical –
loss of primary teeth and the loss of the resulting space
Horizontal 4 (20.0) by adjacent teeth have been suggested by Azeem et al.44
This hypothesis contrasts with these results, considering
Note. There were 20 subjects and 20 transmigrated canines in SG.
that, in this study, the primary canine was present in
Data were analyzed using the c2 test (significance P \0.05).
82.1% of subjects. This is in agreement with the litera-
ture on the topic, which supports the association of
mandibular canine impaction with the persistence of
the homolateral deciduous canine over the physiological
Table III. Descriptive statistics and general and clinical time of exfoliation.50 The deviation of the succedaneous
information comparing SG and CG canine from the normal eruptive path slows down the
resorption processes of the deciduous canine root.5
Variables SG CG t P value
Mean age (y) 14.7 14.9 0.183y 0.853
Other factors most frequently associated with the
Gender impaction of the mandibular canine, such as the IMPA,
Female 23 (45.1) 28 (54.9) 0.980z 0.428 Class II malocclusion, and the enlargement of the sym-
Male 28 (54.9) 28 (45.1) physeal cross-sectional area were examined in this study.
Skeletal Class Only the IMPA value was found to be significantly
I 26 (50.9) 20 (39.2) 1.974z 0.373
II 22 (43.1) 25 (49.0)
increased in subjects with mandibular canine impaction.
III 3 (5.9) 6 (11.7) This finding is in agreement with studies in the literature,
Symphysis anatomy although there exist only case reports,53 case series,32 or
Normal 19 (37.7) 27 (52.9) 4.943z 0.084 small sample studies.31 This study did not aim to eval-
Narrow 16 (31.4) 7 (13.7) uate whether incisor proclination is a cause or effect of
Wide 16 (31.4) 17 (33.3)
mandibular canine impaction but to evaluate a possible
y
Data were analyzed using a Student t test (significance P \0.05); association. Establishing an association between impac-
z
Data were analyzed using a c2 tests (significance P \0.05). tion and increased IMPA may be useful in any case, as it
may indicate a possible risk factor that could be
adequately evaluated in a study with radiographic con-
consistent with previously reported findings.50 In this trols over time. In addition, the use of 3D radiographs
study, the incidence of buccal impaction was higher may, in the future, help to understand possible differ-
than that of lingual impaction, particularly with transmi- ences in subjects with unilateral impaction and different
grated mandibular canines that can migrate buccally to proclination of the mandibular incisors on the 2 sides.
the roots of the incisors51 along the path of least resis- Peck et al29 and Plakwicz et al50 considered that Class
tance3,36 also as a consequence of the more buccal po- II Division 2 malocclusion could be a possible risk factor
sition of bud formation.52 for impaction. However, in this study, the Class II maloc-
The exact etiologic mechanism that causes canine clusion was present in equal measure between the 2
impaction remains unclear, and several theories have groups.

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Guarnieri et al 563

In contrast with the literature,32 this study did not 3. Camilleri S, Scerri E. Transmigration of mandibular canines—a re-
find any correlation between the impaction of the view of the literature and a report of five cases. Angle Orthod 2003;
73:753-62.
mandibular canine and the anatomy of the symphysis.
4. Auluck A, Nagpal A, Setty S, Pai KM, Sunny J. Transmigration of
In this study, transmigration occurred in 39.2% of impacted mandibular canines—report of 4 cases. J Can Dent Assoc
subjects with impacted mandibular canines. These ele- 2006;72:249-52.
ments showed a statistically significant higher mesial 5. Joshi MR. Transmigrant mandibular canines: a record of 28 cases
cusps inclination. This evidence is in agreement with and a retrospective review of the literature. Angle Orthod 2001;71:
12-22.
the retrospective cross-sectional study of Bertl et al22
6. Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and
who analyzed the computed tomography and/or cone- transmigration in a patient population. Dentomaxillofac Radiol
beam computed tomography data of 88 subjects with 2004;33:164-9.
a total of 94 impacted mandibular canines. In this study, 7. Ando S, Aizawa K, Nakashima T, Sanka Y, Shimbo K, Kiyokawa K.
subjects with transmigrated mandibular canines are also Transmigration process of the impacted mandibular cuspid. J Ni-
hon Univ Sch Dent 1964;6:66-71.
positively associated with a higher increased IMPA value
8. Kara MI, Ay S, Aktan AM, Sener I, Bereket C, Ezirganli S, et al. Anal-
than that of subjects with impacted mandibular canines ysis of different type of transmigrant mandibular teeth. Med Oral
and the CG, as also reported by Vichi et al.32 Patol Oral Cir Bucal 2011;16:e335-40.
It could be hypothesized that there is a higher prob- 9. Koç A, Kaya S, Abdulsalam WA. Three-dimensional analysis of
ability of impaction and transmigration of mandibular impacted maxillary and mandibular canines and evaluation of
factors associated with transmigration on cone-beam computed
canine in association with the persistence of the decidu-
tomography images. J Oral Maxillofac Surg 2021;79:538.e1-11.
ous canine, the mesial tipping of the impacted canine 10. Alves DB, Pedrosa EF, Andreo JC, de Carvalho IM, Rodrigues C.
cusps, and the increase of buccal inclination of mandib- Transmigration of mandibular second premolar in a patient
ular incisors. with cleft lip and palate—case report. J Appl Oral Sci 2008;
16:360-3.
11. Shapira Y, Kuftinec MM. The ectopically erupted mandibular
CONCLUSIONS
lateral incisor. Am J Orthod 1982;82:426-9.
The mesialization of the canine cusp and the persis- 12. Lagan
a G, Venza N, Borzabadi-Farahani A, Fabi F, Danesi C,
tence of the mandibular deciduous canine are character- Cozza P. Dental anomalies: prevalence and associations between
them in a large sample of non-orthodontic subjects, a cross-
istics frequently found in patients with mandibular
sectional study. BMC Oral Health 2017;17:62.
canine impaction. An increased IMPA is found to be 13. Dalessandri D, Parrini S, Rubiano R, Gallone D, Migliorati M.
significantly associated with this anomaly. Impacted and transmigrant mandibular canines incidence, aeti-
ology, and treatment: a systematic review. Eur J Orthod 2017;
ACKNOWLEDGMENTS 39:161-9.
14. Dachi SF, Howell FV. A survey of 3,874 routine full-mouth radio-
The authors thank Alison Driver for her assistance in graphs. I. A study of retained roots and teeth. Oral Surg Oral Med
English language editing. Oral Pathol 1961;14:916-24.
15. Thilander B, Jakobsson SO. Local factors in impaction of maxillary
canines. Acta Odontol Scand 1968;26:145-68.
AUTHOR CREDIT STATEMENT
16. Sacerdoti R, Baccetti T. Dentoskeletal features associated with uni-
Rosanna Guarnieri contributed to conceptualization, lateral or bilateral palatal displacement of maxillary canines. Angle
methodology, investigation, validation, data curation, Orthod 2004;74:725-32.
17. Celikoglu M, Kamak H, Oktay H. Investigation of transmigrated
manuscript review and editing, and visualization; Fran-
and impacted maxillary and mandibular canine teeth in an ortho-
cesca German
o; contributed to original draft prepara- dontic patient population. J Oral Maxillofac Surg 2010;68:
tion, software, formal analysis, and investigation; 1001-6.
Giulia Sottile contributed to investigation and resources; 18. Mercuri E, Cassetta M, Cavallini C, Vicari D, Leonardi R, Barbato E.
Ersilia Barbato contributed to supervision and project Dental anomalies and clinical features in patients with maxillary
canine impaction. Angle Orthod 2013;83:22-8.
administration; and Michele Cassetta contributed to
19. Guarnieri R, Cavallini C, Vernucci R, Vichi M, Leonardi R,
conceptualization, validation, supervision, and project Barbato E. Impacted maxillary canines and root resorption of adja-
administration. cent teeth: a retrospective observational study. Med Oral Patol Oral
Cir Bucal 2016;21:e743-50.
REFERENCES 20. Sajnani AK, King NM. Impacted mandibular canines: prevalence
and characteristic features in Southern Chinese children and ado-
1. Litsas G, Acar A. A review of early displaced maxillary canines: eti- lescents. J Dent Child (Chic) 2014;81:3-6.
ology, diagnosis and interceptive treatment. Open Dent J 2011;5: 21. Aras MH, Halicioglu K, Yavuz MS, Ça glaro
glu M. Evaluation of
39-47. surgical-orthodontic treatments on impacted mandibular canines.
2. Suri L, Gagari E, Vastardis H. Delayed tooth eruption: pathogen- Med Oral Patol Oral Cir Bucal 2011;16:e925-8.
esis, diagnosis, and treatment. A literature review. Am J Orthod 22. Bertl MH, Frey C, Bertl K, Giannis K, Gahleitner A, Strbac GD.
Dentofacial Orthop 2004;126:432-45. Impacted and transmigrated mandibular canines: an analysis of

American Journal of Orthodontics and Dentofacial Orthopedics May 2024  Vol 165  Issue 5
564 Guarnieri et al

3D radiographic imaging data. Clin Oral Investig 2018;22: 40. Tweed CH. A philosophy of orthodontic treatment. American Jour-
2389-99. nal of Orthodontics and Oral Surgery 1945;31:74-103.
23. Bhullar MK, Aggarwal I, Verma R, Uppal AS. Mandibular canine 41. G€utermann C, Peltom€aki T, Markic G, H€anggi M, Sch€atzle M,
transmigration: report of three cases and literature review. J Int Signorelli L, et al. The inclination of mandibular incisors revisited.
Soc Prev Community Dent 2017;7:8-14. Angle Orthod 2014;84:109-19.
24. G€und€uz K, Çelenk P. The incidence of impacted transmigrant ca- 42. Mazurova K, Kopp JB, Renkema AM, Pandis N, Katsaros C,
nines: a retrospective study. Oral Radiol 2010;26:77-81. Fudalej PS. Gingival recession in mandibular incisors and symphy-
25. Aktan AM, Kara S, Akg€ unl€u F, Malkoç S. The incidence of canine sis morphology-a retrospective cohort study. Eur J Orthod 2018;
transmigration and tooth impaction in a Turkish subpopulation. 40:185-92.
Eur J Orthod 2010;32:575-81. 43. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible
26. Buyukkurt MC, Aras MH, Caglaroglu M, Gungormus M. Transmi- statistical power analysis program for the social, behavioral,
grant mandibular canines. J Oral Maxillofac Surg 2007;65: and biomedical sciences. Behav Res Methods 2007;39:175-91.
2025-9. 44. Azeem M, Afzal A, Ahmed Z, Ali MM, Haq AU, Hamid WU. Inves-
27. Sajnani AK. Permanent maxillary canines - review of eruption tigation of transmigrated mandibular canines. Dental Press J Or-
pattern and local etiological factors leading to impaction. J Inves- thod 2019;24:65-8.
tig Clin Dent 2015;6:1-7. 45. Mejıa-Milian M, Arriola-Guillen LE, Aliaga-Del Castillo A,
28. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Rodrıguez-Cardenas YA, Ruız-Mora GA. Three-dimensional evalu-
Dentofacial Orthop 1992;101:159-71. ation of mandibular canine impaction characteristics and their
29. Peck S. On the phenomenon of intraosseous migration of noner- relationship with lower incisor root morphometry. J Clin Exp
upting teeth. Am J Orthod Dentofacial Orthop 1998;113:515-7. Dent 2022;14:e791-802.
30. Marks SC Jr, Schroeder HE. Tooth eruption: theories and facts. 46. Cakir Karabas H, Ozcan I, Erturk AF, Guray B, Unsal G, Senel SN.
Anat Rec 1996;245:374-93. Cone-beam computed tomography evaluation of impacted and
31. Kuftinec MM, Shapira Y, Nahlieli O. A case report. Bilateral trans- transmigrated mandibular canines: a retrospective study. Oral Ra-
migration of impacted mandibular canines. J Am Dent Assoc 1995; diol 2021;37:403-11.
126:1022-4. 47. Zvolanek JW. Transmigration of an impacted mandibular canine.
32. Vichi M, Franchi L. The transmigration of the permanent lower Ill Dent J 1986;55:86-7.
canine. Minerva Stomatol 1991;40:579-89. 48. Peck S, Peck L, Kataja M. Prevalence of tooth agenesis and peg-
33. Jain S, Shetty KS, Prakash AT, Agrawal M, Jain S. Permanent shaped maxillary lateral incisor associated with palatally displaced
mandibular canine(s) impaction: expansion of our understanding. canine (PDC) anomaly. Am J Orthod Dentofacial Orthop 1996;110:
Aust Orthod J 2014;30:39-44. 441-3.
34. Costello JP, Worth JC, Jones AG. Transmigration of permanent 49. Dhooria HS, Sathawane RS, Mody RN, Sakarde SB. Transmigra-
mandibular canines. Br Dent J 1996;181:212-3. tion of mandibular canines. J Indian Dent Assoc 1986;58:
35. Alaejos-Algarra C, Berini-Aytes L, Gay-Escoda C. Transmigration 348-51: 357.
of mandibular canines: report of six cases and review of the liter- 50. Plakwicz P, Czochrowska E, Kukula K. Impacted and transmigrant
ature. Quintessence Int 1998;29:395-8. mandibular canines incidence, aetiology, and treatment: a system-
36. Nodine AM. Impacted and aberrant teeth: their history, causes and atic review. Eur J Orthod 2018;40:226-7.
treatment. Dent Items Interest 1946;68:1164: passim. 51. Yu HB, Huang Y, Zhang LP, Hong MJ, Yang XH. A clinical analysis
37. Bhoweer AL, Ranpise S. Transmigration of the mandibular canine: of 11 mandibular impacted canines. Int J Clin Exp Med 2019;12:
a report of two rare cases. IJSS 2014;7(1):4. 11504-10.
38. Howard RD. The anomalous mandibular canine. Br J Orthod 1976; 52. Kaufman AY, Buchner A, Gan R, Hashomer T. Transmigration of
3:117-21. mandibular canine. Report of a case. Oral Surg Oral Med Oral
39. Cernochova P, Izakovicova-Holla L. Dentoskeletal characteristics Pathol 1967;23:648-50.
in patients with palatally and buccally displaced maxillary perma- 53. Kerr WJ. A migratory mandibular canine. Br J Orthod 1982;9:
nent canines. Eur J Orthod 2012;34:754-61. 111-2.

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