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+ MODELJournal of Dental Sciences (2013) xx, 1e7

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CASE REPORT

Orthodontic treatment of a complete transposedimpacted maxillary canine

Pi-Huei Liu a,b, Eddie Hsiang-Hua Lai a,b, Hsiang Yang b,Jenny Zwei-Chieng Chang a,b*

aDepartment of Orthodontics, National Taiwan University Hospital, Taipei, TaiwanbGraduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan

Received 19 June 2011; Final revision received 6 October 2011

Available online - - -

KEYWORDSimpaction;maxillary canine;tooth transposition

* Corresponding author. School ofUniversity, Number 1, Changde Street

E-mail address: jennyzc@ms3.hine

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Abstract Tooth transposition is a positional interchange of two adjacent teeth. Transpositionmost often occurs at maxillary canine. Moving transposed teeth to their normal positions ischallenging because this requires bodily movement and translation of one tooth to passanother. This procedure may cause damage to the teeth or supporting structures. We reporta case of complete transposition of maxillary canine and lateral incisor. Transposed teeth weresuccessfully moved orthodontically to their normal positions. Multiple mechanics were metic-ulously applied to achieve complete correction of the tooth positions and to minimize rootresorption and/or periodontal defects of canine and lateral incisors. Factors concerning treat-ment planning for transposed teeth are discussed.Copyright ª 2013, Association for Dental Sciences of the Republic of China. Published byElsevier Taiwan LLC. All rights reserved.

Introduction

Tooth transposition is a positional interchange of two adja-cent teeth. It is identified as complete transposition when

Dentistry, National Taiwan, Taipei 10048, Taiwan.t.net (J.Z.-C. Chang).

P-H, et al., Orthodontic treatmei.org/10.1016/j.jds.2013.02.015

iation for Dental Sciences of the Re2.015

the crowns and the roots of the involved teeth exchangeplaces in the dental arch, and incomplete transposition (orpseudotransposition) when the crowns are transposed butthe roots remain in their normal positions.1 Tooth trans-position occurs more often unilaterally than bilaterally, withmaxillary prevalence, and no sex preference. Tooth trans-position is significantly unrelated to dental anomalies, suchas congenitally missing teeth, peg-shaped or hypoplasticteeth, and impacted teeth. Although tooth transposition

nt of a complete transposed impacted maxillary canine, Journal of

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Figure 1 Pretreatment extraoral and intraoral photographs.

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may be associated with over-retained deciduous teeth, it isan isolated phenomenon rather than a syndrome.2

The etiology of tooth transposition appears to begenetically involved. Transposition most often occurs at

Figure 2 Pretreatment

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maxillary canine.3 Peck and Peck4 reviewed 71 articles witha total of 201 cases of maxillary tooth transpositions, andclassified 71% of the cases as maxillary canineefirst pre-molar transposition, 20% as canineelateral incisor, 4% as

panoramic radiograph.

nt of a complete transposed impacted maxillary canine, Journal of

Table 1 Cephalometric analysis.

Pretreatment Post-treatment

Norm(mean � SD)

Skeletal measurements

SNA 83.5� 83.5� 82.5 � 3.5SNB 82.5� 81.5� 77.7 � 3.2ANB 1� 2� 4.0 � 1.8A-Nv �1 mm �1 mm 0 � 2Pog-Nv �5.5 mm �7.5 mm �5 � 8NAP 3� 6� 5.1 � 3.8Wit’s appraisal �7.5 mm �7 mm \:0/_:�1SN-FH 5� 5� 5.7 � 3.0SN-MP 31� 33� 33.0 � 1.8UFH/LFH 43.6/56.4 42.8/57.2 45%/55%Dental measurements

U1-SN 103� 104� 108.2 � 5.4L1-MP 87� 85� 93.7 � 6.3U1-L1 139� 138� 119.9 � 8.5U1-NP 4 mm 8 mm 6.4 � 2.7UADH 31.5 mm 33 mm 29 � 2UPDH 26 mm 27 mm 20 � 2LADH 45.5 mm 46.5 mm 45 � 3LPDH 38 mm 38 mm 35 � 3ANB: Point A-Nasion-point B angle; A-Nv: mm distance fromNasion perpendicular to point A; L1-MP: angle between long axisof lower central incisor and mandibular plane; LADH: loweranterior dental height (distance from lower central incisor edgeto mandibular plane); LPDH: lower posterior dental height(distance from lower first molar mesio-buccal cusp tip tomandibular plane); NAP: Nasion-point A-Pogonion angle; Pog-Nv: mm distance from Nasion perpendicular to Pogonion; SD:standard deviation; SNA: Sella-Nasion-point A angle; SNB: Sella-Nasion-point B angle; SN-FH: angle between Sella-Nasion lineand Frankfort plane; SN-MP: angle between Sella-Nasion lineand mandibular plane; U1-L1: angle between long axis of lowerand upper central incisors; U1-NP: mm distance from upperincisor incisal edge measured linearly perpendicularly toNasion-Pogonion plane; UADH: upper anterior dental height(distance from upper central incisor edge to palatal plane);UPDH: upper posterior dental height (distance from upper firstmolar mesio-buccal cusp tip to palatal plane); UFH/LFH: upperfacial height to lower facial height ratio; U1-SN: angle betweenlong axis of upper central incisor and Sella-Nasion line; Wit’sappraisal: mm distance of projections from point A and B to theocclusal plane.

Complete transposed maxillary canine 3

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canineefirst molar, 3% as central incisorelateral incisor,and 2% as canine and central incisor transposition.

Moving transposed teeth to their normal positions isquite challenging because this requires bodily movementand translation of one tooth to pass another tooth. Thisprocedure may cause damage to the teeth and the sup-porting structures. Hence, in the case of complete trans-position, alignment of the teeth in their transposedpositions is often suggested; however, reshaping the crownsshould be performed in order to achieve an acceptableaesthetic result.

This is a report of a case with complete transposition ofleft maxillary canine and lateral incisor. The teeth weremeticulously moved orthodontically to their normalpositions.

Please cite this article in press as: Liu P-H, et al., Orthodontic treatmeDental Sciences (2013), http://dx.doi.org/10.1016/j.jds.2013.02.015

Case report

A24-year-old female attended theOrthodonticDepartment ofNational Taiwan University Hospital with the chief complaintof impacted maxillary canines. Clinical examinations showednormal facial proportions, mild gummy smile, and mild chindeviation to the right side (Fig. 1). The lateral profile was thestraight profile. Bilateral maxillary primary canine were over-retained. The overjet was �0.5 mm and the overbite was1 mm. Bilateral Angle Class I molar relationships were noted.There was a 2-mm space deficiency in the maxillary dentitionand a 2-mm space excess in the mandibular dentition.

A panoramic radiograph revealed that the left maxillarycanine was impacted between the central and lateral in-cisors while the right maxillary canine was impacted be-tween the lateral incisor and the primary canine (Fig. 2).Lateral cephalometric analysis of the pretreatment dataindicated a facial pattern of the skeletal Class I jaw rela-tionship with an average mandibular plane angle (Table 1).The left maxillary canine was diagnosed as palatal to theleft maxillary lateral incisor using the buccal object rule.

The patient was diagnosed as having mild facial asym-metry and Class I malocclusion with complete transpositionof the left maxillary canine and lateral incisor. The treat-ment objectives were to establish normal overjet andoverbite, to align bilateral maxillary canines, and to closemandibular spacing.

Two treatment options were offered to the patient. Thefirst treatment plan was to extract bilateral primary caninesand to align the right maxillary canine to its normal positionwhile aligning the left maxillary canine to its transposed po-sition. This treatment option would warrant shorter treat-ment time; however, themaxillary left canine would need tobe reshaped and the lateral incisor restored. Because the leftmaxillary canine was palatal to the left lateral incisor, suffi-cient bone was available surrounding the canine, and afavorable crown-to-root ratio was noted for both left maxil-lary lateral incisor and canine, an alternative treatment planwas to extract bilateral primary canines and to align bothmaxillary canines into their normal positions. This would costmore time to treat, but would result in better aesthetics andocclusion. The patient chose the second treatment plan.

Treatment progress

Treatment was initiated with a 0.018-inch slot edgewiseappliance (Dentaurum, Ispringen, Germany) placed on themaxillary teeth. After initial leveling and alignment with a0.016-inch nickeletitanium (NiTi) archwire (ORMCO Corpo-ration, Glendora, CA, USA), the maxillary left canine wassurgically exposed and a lingual button with eyelet ligaturewire was bonded (Fig. 3A and B). A 0.016-inch � 0.022-inchthe titanium-molybdenum alloy of TMA wire (ORMCO Cor-poration, Glendora, CA, USA) with labial root torque appliedon the left lateral incisor allowed labial movement of theroot, whereas a transpalatal arch was inserted to facilitatemoving the leftmaxillary canine palatally (Fig. 3C). After themaxillary left canine reached a position palatal enough tobypass the lateral incisor without damage, amaxillary 0.016-inch � 0.022-inch stainless steel main archwire (ORMCOCorporation, Glendora, CA, USA) was placed and a 0.018-

nt of a complete transposed impacted maxillary canine, Journal of

Figure 3 Treatment progress of left maxillary canine traction. (A) The left maxillary canine was surgically exposed. (B) A lingualbutton with eyelet ligature wire was bonded on the exposed tooth. (C) A transpalatal arch was used to move the left maxillarycanine palatally. (D) A 0.017-inch � 0.022-inch stainless steel spring was attached to the palatal side of the left maxillary firstpremolar to erupt and distalize the canine. (E) A torquing spring was placed on the main archwire to erupt and distalize the leftmaxillary canine. (F) An elastic thread for correction of canine rotation. (G) A 0.014-inch nickeletitanium (NiTi) overlay wire wasused to align the left maxillary canine (frontal view). (H) A 0.014-inch NiTi overlay wire was used to align the left maxillary canine(occlusal view).

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inch slot edgewise bracketwas bonded on the lingual surfaceof the maxillary left premolar and a 0.017-inch � 0.022-inchstainless steel extrusive spring was attached on the lingualbracket to move the left maxillary canine occlusally anddistally (Fig. 3D). Ten months later, a torquing spring wasplaced on themain archwire to enhance canine eruption anddistalization (Fig. 3E). After the left maxillary canine haderupted into the oral cavity, an additional elastic thread wasused to derotate the canine (Fig. 3F). The left maxillarycanine was bonded with an edgewise bracket on the buccalside after partial correction of the rotation. The bracket wasintentionally bonded upside down to increase labial roottorque. A 0.014-inch NiTi overlay wire (ORMCO Corporation,Glendora, CA, USA) was used for initial leveling and align-ment of the left maxillary canine (Fig. 3G and H) followed bya continuous 0.016-inch� 0.022-inchmaxillary NiTi archwire(ORMCOCorporation, Glendora, CA, USA) to finish leveling. Amandibular orthodontic appliance was placed at the timewhen the maxillary left canine was almost in its normal

Please cite this article in press as: Liu P-H, et al., Orthodontic treatmeDental Sciences (2013), http://dx.doi.org/10.1016/j.jds.2013.02.015

position. The total active treatment time was 42 months.The teeth were retained with maxillary and mandibularremovable Hawley appliances.

Treatment results

The treatment results for this patient were excellent. Allteeth were well aligned in their proper positions (Fig. 4).Bilateral Class I occlusion with normal overjet and overbitewere achieved. The spacing in the mandibular arch wasclosed. The maxillary and mandibular dental midlines werecoincident to the facial midline. All treatment objectiveswere obtained. A panoramic radiograph revealed good rootparallelism with minimal root resorption (Fig. 5). Post-treatment cephalometric data (Table 1) and the cephalo-metric superimposition (Fig. 6) showed extrusion of maxil-lary incisors and molars accompanied with a clockwiserotation of the mandible. The patient was satisfied with herteeth and profile.

nt of a complete transposed impacted maxillary canine, Journal of

Figure 4 Post-treatment extraoral and intraoral photographs.

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Discussion

Among dentitional anomalies, tooth transposition isconsidered one of the most difficult to manage. Treatmentoptions for these transposed teeth include alignment of

Figure 5 Post-treatment

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teeth in their transposed positions, correction of the teethto their normal position, and extraction of one or bothtransposed teeth.5 Peck and Peck suggested that teeth withpseudotransposition could be corrected into their normalpositions; however, correction was not recommended for

panoramic radiograph.

nt of a complete transposed impacted maxillary canine, Journal of

Figure 6 Post-treatment cephalometric radiograph and superimposition of pretreatment (in black line) and post-treatment (inred line) cephalometric tracings.

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6 P.-H. Liu et al

the teeth with complete transposition.4 Still, very fewcases of correction of complete transpositions have beenreported.6e11 Shapira and Kuftinec stated that the correc-tion was complex and could be damaging to both teeth andsupporting structures12; all of the reported successful caseshave been treated with great care to avoid contact be-tween the teeth when creating the passage for the trans-posed teeth.

Figure 7 Strategies used to guide the transposed leftmaxillary canine into the normal position. (A) The left maxil-lary canine was impacted to the palatal side in between theleft central and lateral incisors. (B) Moving the canine palatallyand the root of the lateral incisor buccally. (C) Extrude anddistalize the canine to bypass the lateral incisor. (D) Caninederotation and alignment. (E) Complete alignment of themaxillary dentition.

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Factors to be considered when making treatment plansfor a transposed tooth include dental morphology, occlusalconsiderations, facial aesthetics, stage of root develop-ment, position of the root apices, and treatment time.13e15

Extraction is indicated when reshaping is difficult for atransposed tooth with strange crown morphology. The rootshape of the tooth and the degree of root completionshould also be examined to avoid fenestration especially incases with root dilacerations. When replacing the caninewith the first premolar, the roots of the maxillary firstpremolar must have proper morphology to allow for thenecessary rotation without generating buccal root fenes-trations. Because the periapical and panoramic radiographsof this patient did not reveal abnormalities in crown or rootforms, the left maxillary canine was considered suitable tobe guided into its normal position.

The underlying malocclusion, both morphological andfunctional, and the possibility of obtaining canine-guided orgroup function occlusion influence the choice of treatment.This was originally a Class I malocclusion case with nodental protrusion or crowding; thus, a nonextractiontreatment plan and translation of the left maxillary canineto its normal position would result in better aesthetics andocclusal relationships. If the left maxillary canine wereextracted, posterior teeth would have to be protractedforward in order not to deteriorate the facial profile, andthe orthodontic treatment mechanics would be moredifficult.

The sufficiency of the buccolingual width of the sup-porting alveolar bone is an important aspect when movingtwo adjacent teeth in different directions. Compressionand friction during correction can cause iatrogenic damageto the teeth (such as root resorption) and periodontal tis-sues (such as clefting and recession of gingival tissue). Thebuccolingual width of the alveolar bone of this patient wassufficient and the left maxillary canine had not erupted;thus, moving the canine into its normal position would befeasible as long as the tooth movement in the three planesof space was fully controlled.

nt of a complete transposed impacted maxillary canine, Journal of

Complete transposed maxillary canine 7

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According to a review article concerning the manage-ment of impacted maxillary canines, surgical exposure andorthodontic eruption of palatally impacted maxillary ca-nines have minimal effects on the periodontium.16 Our re-sults showed clinically acceptable periodontal conditionswith some palatal gingival recession after treatment. Thegingival recession on the palatal side would not cause amajor problem because an altered passive eruption wassuspected to have occurred. The patient exhibited mildgummy smile and short clinical crowns before the treat-ment. She had a rather flat smiling arc and excessivedisplay of lower anterior teeth. Thus, we allowed someextrusion of the maxillary incisors to create a more curvedand pleasing smiling arc. The problem of excessive gumdisplay may be corrected afterwards by periodontal plasticsurgery of the dentogingival junction.

Treatment time for either correction or acceptance ofthe transposed position must be considered from a cost-ebenefit point of view. The patient chose to have thecanine moved into its normal position, and was wellinformed that it would cost more time. Cephalometric su-perimposition (Fig. 6) showed a clockwise rotation of themandible after the treatment. This implied that verticalcontrol was lost during treatment. Had temporary anchor-ages devices been included in the treatment plan, themechanics could have been simplified and the treatmenttime shortened.

Because the patient preferred moving the maxillarycanine to its normal position, controlling the tooth move-ment in the alveolar bone was very important. Differentstrategies were used during the treatment (Fig. 7). The firststep was to move the canine palatally and move the root ofthe lateral incisor buccally (Fig. 7A and B). The second stepwas to let the canine bypass the lateral incisor (Fig. 7C).After the transposed canine had bypassed the lateralincisor, canine derotation and alignment was initiated andthe buccal root torque of the lateral incisor was decreasedto obtain normal inclination (Fig. 7D and E). The totaltreatment time for this case was 3 years and 6 months, andthe results were satisfactory. With careful control of thetooth movement in the three planes of spaces, transposedteeth may be brought into their normal positionssuccessfully.

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References

1. Shapira Y, Kuftinec MM, Stom D. Maxillary canine-lateral incisortransposition-orthodontic management. Am J Orthod Dento-facial Orthop 1989;95:439e44.

2. Papadopoulos MA, Chatzoudi M, Karagiannis V. Assessment ofcharacteristic features and dental anomalies accompanyingtooth transposition: a meta-analysis. Am J Orthod DentofacialOrthop 2009;136:308.e1e10. discussion 308e9.

3. Peck L, Peck S, Attia Y. Maxillary canine-first premolar trans-position, associated dental anomalies and genetic basis. AngleOrthod 1993;63:99e109. discussion 110.

4. Peck S, Peck L. Classification of maxillary tooth transpositions.Am J Orthod Dentofacial Orthop 1995;107:505e17.

5. Eddie HH, Lai FHC. Analysis of teeth transposition. J TaiwanAssoc Orthod 2004;16:38e43.

6. Bocchieri A, Braga G. Correction of a bilateral maxillarycanine-first premolar transposition in the late mixed dentition.Am J Orthod Dentofacial Orthop 2002;121:120e8.

7. Laino A, Cacciafesta V, Martina R. Treatment of tooth impac-tion and transposition with a segmented-arch technique. J ClinOrthod 2001;35:79e86.

8. Laptook T, Silling G. Canine transpositiondapproaches totreatment. J Am Dent Assoc 1983;107:746e8.

9. Halazonetis DJ. Horizontally impacted maxillary premolar andbilateral canine transposition. Am J Orthod Dentofacial Orthop2009;135:380e9.

10. Giacomet F, Araujo MT. Orthodontic correction of a maxillarycanine-first premolar transposition. Am J Orthod DentofacialOrthop 2009;136:115e23.

11. Galvao Mde A, Cabral AC, Nishio C, Capelli Junior J. Ortho-dontic management of a transposed maxillary canine andlateral incisor. J Clin Orthod 2007;41:377e81.

12. Shapira Y, Kuftinec MM. Tooth transpositionsda review of theliterature and treatment considerations. Angle Orthod 1989;59:271e6.

13. Ciarlantini R, Melsen B. Maxillary tooth transposition: corrector accept? Am J Orthod Dentofacial Orthop 2007;132:385e94.

14. Nagaraj K, Upadhyay M, Yadav S. Impacted maxillary centralincisor, canine, and second molar with 2 supernumerary teethand an odontoma. Am J Orthod Dentofacial Orthop 2009;135:390e9.

15. Weeks EC, Power SM. The presentations and management oftransposed teeth. Br Dent J 1996;181:421e4.

16. Marisela MB, Jae HP. A review of the diagnosis and manage-ment of impacted maxillary canines. J Am Dent Assoc 2009;140:1485e93.

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Orthodontic treatment of a complete transposed impacted maxillary canineIntroductionCase reportTreatment progressTreatment results

DiscussionReferences