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Rom J Morphol Embryol 2014, 55(3 Suppl):1197–1202

RJME
CASE REPORT Romanian Journal of
Morphology & Embryology
http://www.rjme.ro/

A rare case of canine anomaly – a possible algorithm for


treating it
LIGIA VAIDA1), BIANCA IOANA TODOR1), CLAUDIA COREGA2), MIHAELA BĂCIUŢ3), GRIGORE BĂCIUŢ4)
1)
Department of Dentistry, Faculty of Medicine and Pharmacy, University of Oradea, Romania
2)
Department of Orthodontics, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3)
Department of Implantology and Maxillofacial Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca,
Romania
4)
Department of Oral and Maxillofacial Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Abstract
Canine transmigration is a very rare dental anomaly in which an unerupted mandibular canine migrates, crossing the mandibular midline.
This unusual condition is most often diagnosed by chance during a routine X-ray examination. The most common clinical signs announcing
the presence of this anomaly are over-retention of the deciduous canine and the absence of permanent canine from the dental arch after its
physiological period of eruption. In this paper, we present a clinical case, 10-year-old boy, who was diagnosed with mandibular right canine
transmigration at three years after the start of orthodontic treatment, during which we were expecting the eruption of mandibular canines.
The orthopantomograph revealed the mandibular right canine to be in a horizontal position under the apices of the incisors – type 2
transmigration pattern classified by Mupparapu (2002). Based on cone-beam computer tomography examination, we recommended a surgical
exposure of the canine and orthodontic alignment. Due to the risk of root resorption of the mandibular right lateral incisor during orthodontic
movement phase of canine transmigrated to the dental arch, we decided to align the mandibular right canine in a transposition, between the
two mandibular right incisors. Then we resorted to adapting the mandibular right lateral incisor coronary morphology to simulate a canine
and also to reshaping the canine coronary morphology to resemble a lateral incisor. This therapeutic approach allowed us to restore
morphologically and functionally the mandibular dento-alveolar arch, preserving the entire dental system.
Keywords: transmigrated canine, orthodontic treatment, canine coronary morphology, laterals incisor coronary morphology.

 Introduction supernumerary teeth, cysts and tumors, and an excessive


crown length of the mandibular canine [8, 12]. In the
According to the literature, canine transmigration is a literature, there is no clear evidence to prove that the
very rare and unusual dental anomaly [1–3]. Joshi (2001) canine transmigration could be congenitally inherited.
defined transmigration as the migration of a tooth across In 2002, Mupparapu used five criteria to classify the
the jaw midline without the influence of any pathological transmigrated mandibular canines depending on its path
entity [4]. Tarsitano et al. (1971) suggested that trans- of deviation. Type 1: Positioned mesioangularly across the
migration is a phenomenon in which an unerupted mandi- midline within the jaw bone, labial or lingual to anterior
bular canine migrates, crossing the mandibular midline teeth, and the crown portion of the tooth crossing the
[5]. According to Javid (1985), transmigration should be midline (45.6%). Type 2: Horizontally impacted near the
considered when half of the length of the crown crosses inferior border of the mandible below the apices of the
the midline [1]. incisors (20%). Type 3: Erupting either mesial or distal to
The occurrence of transmigration of mandibular canines the opposite canine (14%). Type 4: Horizontally impacted
varies from 0.14% to 0.31% [6, 7]. While canine impaction near the inferior border of the mandible below the apices of
affects the maxilla much more frequently than the mandible either premolars or molars on the opposite side (17%).
canine, transmigration is found more frequently in the Type 5: Positioned vertically in the midline (the long
mandible. Also, the unilateral canine transmigration is axis of the tooth crossing the midline) irrespective of
more common than the bilateral canine transmigration, eruption status (1.5%) [13].
especially at the mandible [1, 4, 6–8]. Aktan et al. (2010) This paper aims at reporting a case of transmigration
reported incidence of maxillary canine transmigration of mandibular canine, at discussing the importance of
as 0.14% and the incidence of mandibular canine trans- early diagnosis and treatment planning and at presenting
migration as 0.34%, with the right side affected more our option for canine transmigration treatment in order
often than the left side in both jaws [6]. There is clinical to restore the mandibular dento-alveolar arch, morpho-
evidence where canine transmigration may be associated logically and functionally.
with transmigration of other teeth [9, 10].
The mechanism that causes this canine transmigration
 Patient, Methods and Results
is still not clear [11]. However, there are some assumptions
considering the following etiological factors: retention This paper presents a clinical case diagnosed with this
or premature loss of primary teeth, crowding, spacing, rare anomaly, canine transmigration, that we approached

ISSN (print) 1220–0522 ISSN (on-line) 2066–8279


1198 Ligia Vaida et al.
by surgical exposure and orthodontic treatment. Unlike right canine to be in a horizontal position under the apices
other cases of canine transmigration presented in the of the incisors – type 2 transmigration pattern classified
literature, in this case the transmigration of canine by Mupparapu (2002) (Figure 5) [13]. This transmigrated
occurred during the period when the patient was under canine was radiographically seen to be surrounded by a
orthodontic treatment. cystic lesion.
The patient, a 10-year-old boy, presented to our clinic
Surgical exposure and orthodontic alignment
in 2007 requiring treatment of dental crowding. During
of the canine
the clinical examination, we noticed the presence of mixed
dentition, a delayed dentition, permanent teeth being only As a result of a began cone-beam computer tomo-
the first molars and incisors on both dental arches. The graphy (CBCT) examination (Figure 6), that revealed the
medical examination and treatment was conducted with presence of a dentiger cyst surrounding the transmigrated
the written informed consent of his mother who was also canine and its relationship with the neighboring anatomical
instructed regarding our intention to include this case in structures, we decided to recommend a surgical inter-
a scientific paper. vention, in order to perform a canine exposure and
bonding of attachment to allow subsequent orthodontic
First radiological examination
traction of the canine (Figure 7).
Upon radiological examination (orthopantomograph The canine distalization and uprighting were possible
– Figure 1), we found the presence of a mixed dentition, only using skeletal anchorage represented of mini-implant,
deciduous teeth presenting complicated decays and large otherwise there was a high risk to damage other teeth
coronary destructions. Intramaxillary, one could see the from the dental arch (Figure 8).
presence of all permanent teeth buds. In that period, we During orthodontic movement phase of canine trans-
did not associate the slight mesial inclination of the migrated to the dental arch, we reassessed, using CBCT
mandibular right canine bud with a possible pathological investigation, the canine position and its relationship with
evolution. incisors roots. We noticed the risk of root resorption of
the mandibular right lateral incisor. This observation led
us to the decision to distalize the mandibular right lateral
incisor in contact with the first premolar, by using ortho-
dontic forces, and to align the mandibular right canine in
a transposition, between mandibular right lateral incisor
and mandibular right central incisor (Figure 9).
After aligning the mandibular right canine in the
dental arch between the two incisors, we found a canine
gingival retraction. CBCT revealed the lack of vestibular
bone support of the canine. These findings led us to the
need for intervention of canine periodontal surgery after
removing the orthodontic appliance.
Figure 1 – Orthopantomograph from the beginning
of the orthodontic treatment: 10-year-old patient with
Periodontal surgery procedure
mixed dentition. Based on clinical examination corroborated with para-
clinical examination (CBCT), it was noticed gingival
Orthodontic treatment
retraction at canine, Class 3 Miller, as well as bone loss
We started the orthodontic treatment of the maxillary at buccal alveolar ridge of the respective tooth. Using a
dental arch with a removable appliance. In the mandibular bone collecting single use tool, it was taken autologous
dental arch, we found the presence of tooth eruption bone at the level of chin using the scraping technique.
disorders with persistent deciduous canines after the The approximately one square centimeter bone sample
eruption of second premolars (Figure 2). was used to cover the bone deficiency at the alveolar
After one year of treatment, during which the lateral vestibular level of canine (Figure 10). Therewith were done
incisors and premolars erupted in maxillary dental arch horizontal excisions of ties scars and lower labial frenulum
(Figure 3), we continued upper arch treatment with a fixed in order to avoid the possible subsequent tractions of the
appliance without requiring the patient a new orthopan- flap.
tomograph for avoiding additional radiation.
Morphological and functional restoration of
Subsequently, we observed in the mandibular dental
the dental arch
arch delayed left permanent canine eruption while the
right deciduous canine continued to persist. Then, we Morphological and functional restoration of the
decided to extract the deciduous mandibular right mandibular dental arch at the end of the orthodontic
canine (Figure 4) and to start orthodontic treatment with treatment, according to this complete therapeutic trans-
fixed appliance in the mandibular dental arch. position, involved adjusting the lateral incisor crown in
order to give it the morphological aspect of a canine and
Second image examination also reshaping the canine coronary morphology to resemble
We asked the patient to take a new radiological a lateral incisor. For this purpose, we focused on the
investtigation after three years from the beginning of the application of a veneer on the lateral incisor and composite
treatment. Panoramic radiograph revealed the mandibular angular addition on the canine crown (Figure 11).
A rare case of canine anomaly – a possible algorithm for treating it 1199

Figure 2 – Mandibular dental arch: Figure 3 – Intraoral aspect before treatment with orthodontic fixed appliance:
tooth eruption disorders (eruption of (a) Maxillary dental arch – lack of space for permanent canines’ eruption;
second premolar before canines’ (b) Frontal occlusion.
eruption).

Figure 4 – Intraoral aspect after applying


the maxillary fixed appliance: (a) Ortho-
dontic treatment phase in the upper dental
arch; (b) Mandibular dental arch after
extraction of lower right deciduous canine.
Note the delayed eruption of lower left
canine in a severe disto-vestibular rotation.

Figure 5 – (a and b) Ortho-


pantomograph after three
years from the beginning
of the treatment shows the
lower right canine trans-
migration (red arrows)
in a horizontal position
under the apices of
the incisors.

Figure 6 – (a–c) CBCT, the axial sections showing the anatomical relationship of transmigrated canine with the lower
incisors roots.

Figure 7 – Intraoperative and postoperative aspect: (a) The osseous cavity after Figure 8 – Orthodontic treatment
the enucleation of the dentiger cyst; (b) The first system of canine orthodontic phase, distalization of lateral incisor
traction to the dental arch. and orthodontic retraction of the
transmigrated canine using a mini-
implant.
1200 Ligia Vaida et al.

Figure 9 – Orthodontic treatment phase:


(a) Mandibular dental arch with lower
right canine aligned between lower
lateral incisor and central incisor;
(b) Frontal occlusion during orthodontic
treatment.

Figure 10 – Periodontal surgery: intraoperative


images. Flap coronary moved surgery at 4.3–3.3
level followed by bone augmentation.

Figure 11 – Intraoral aspect at the end of the treatment: (a) Occlusion of the
right half profile; (b) Frontal occlusion; (c) Occlusion of the left half profile;
(d) Mandibular dental arch – the right canine crown was reshaped to
simulate a lateral incisor and the right lateral incisor crown
was also reshaped to simulate a canine.

 Discussion treatment for transmigrated canines, rather than making


effort to bring the tooth to its original place. This is
Migration of a tooth across the midline is a rare
especially indicated when the mandibular teeth are
anomaly. However, at least 157 cases of mandibular canine
crowded and require therapeutic extractions to correct
transmigration were already published 10 years ago [3,
the incisor crowding [11].
14, 15]. Until 2011, 196 cases of mandibular canine trans-
(2) Surgical exposure and orthodontic alignment. Few
migration have been reported [16]. This anomaly creates
of the orthodontists succeeded successfully orthodontic
surgical, orthodontic, interceptive and restorative problems.
alignment of transmigrated canines on the dental arch [17].
The most transmigrated canines are asymptomatic and
therefore the patients are not aware of this condition. Wertz used orthodontic treatment to bring three labial
Most of these transmigrated canines are usually detected transmigrated canines into position [18]. Kumar et al.
during routine radiological examinations. In order to (2012) reported success in orthodontic treatment of a
confirm the diagnosis, the following types of radiographs transmigrated lower left canine, which was located with
may be used: dental pantomographs, occlusal, periapical, its crown below the apices of the right central incisor
lateral cephalometric and three-dimensional investigations [19]. Camilleri and Scerri (2003) suggested that if the
(cone-beam computer tomography is likely to be preferred crown of such a tooth migrates past the opposite incisor
nowadays). However, there are some clinical signs of area or if the apex migrated past the apex of the adjacent
transmigration that have been reported, such as: over- lateral incisor, it might be mechanically impossible to
retention of the deciduous canine, proclination of the bring it into place [11].
mandibular anterior teeth, an enlarged symphyseal area, (3) Transplantation. If the mandibular teeth are not
and chronic infection with fistulization [6, 11]. crowded, incisors are in a normal position and the space
In our study, three factors might possibly cause the for the transmigrated canine is sufficient, transplantation
transmigration: over-retention of the deciduous mandibular may be a choice.
right canine, mesial inclination of the canine bud and the (4) Observation (radiographic monitoring). Trans-
presence of the dentigerous cyst. migrated canines can be left in place and kept under
There are several treatment options proposed for observation until the appearance of the first symptoms
unerupted canines: such as the existence of pressure, roots resorption of
(1) Surgical removal appears to be the most favorable the adjacent teeth, periodontal disturbances, prosthetic
A rare case of canine anomaly – a possible algorithm for treating it 1201
problems, malposition of the adjacent teeth, neuralgic the second molar and third molar on the opposite side
symptoms, a progressive worsening of the position of the [23, 26].
canine or suggestion of cystic change. These symptoms In our study, transmigrated canine orthodontic treat-
represent indications for surgical interventions. In these ment would not have been possible without holding prior
situations, a series of successive radiographs should be information provided by CBCT, a radiological investi-
taken periodically [12, 17, 20]. Most authors stated that gation that revolutionized the bone analysis and treat-
transmigrated canines usually have to be removed rather ment planning. The information revealed by CBCT is
than a heroic effort to reposition them to their original needed for a lot of purposes, such as: assessment of bone
place [20–22]. support; examination of teeth and facial structures to start
Auluck et al. (2006) reported four cases of mandibular orthodontic treatment; examination of the relationship
canine transmigration, all detected after the age of 20- between the impacted teeth and the neighboring anato-
year-old, of whom three symptomatic and one asympto- mical structures; diagnosis of cysts, tumors or infections
matic and emphasized the importance of early diagnosis of the teeth and jaw bones [27, 28]. We requested a new
and early treatment to avoid complications [23]. CBCT investigation during orthodontic retraction canine
In the clinical case presented by us, mandibular canine phase to assess its position and its relationship with
transmigration occurred in a period of three years. incisors’ roots.
Despite the fact that there was a mesial inclination of Also, transmigrated canine orthodontic movement
mandibular right canine bud with 390 (Figure 12), we did toward dental arch would have been extremely difficult,
not suspect it then as a possible pathological evolution, if not impossible, without the use of skeletal anchorage
so that we did not propose to follow the case from this represented by mini-implant. Mini-implants are an excellent
point of view. The left mandibular permanent canine alternative to conventional orthodontic anchorage systems
that delayed erupting led us to consider the existence of such as intraoral dental anchoring units, which run the
disturbances in the eruption sequence of the mandibular risk of severely damaging the teeth. Other advantages
canines and, therefore, we did not ask the patient to take include their relatively small size, which results in minimal
anatomical limitations, user-friendly protocol, immediate
a new orthopantomography earlier than it could show
loading potential, adaptability to biomechanics in effecting
the tendency to transmigration. Our study highlights
orthodontic and orthopedic forces, high success rate, low
the importance of clinical and radiological following of
cost and, most importantly, patient acceptability. The
mandibular canines’ eruption especially when there is a
use of orthodontic mini-implant simplified the treatment
more pronounced mesial tilt.
plan and allowed us a maximum conservation of tooth
structures [29–31].
Figure 12 – The axial
inclination of the
With respect to the treatment of these canines, inter-
mandibular right ceptive treatment should be carried out, although it is
canine bud to mid- extremely difficult, if not impossible, to predict the
sagittal plane, α=390, appearance of this anomaly. For Joshi (2001), predicting
at the beginning of the appearance of this anomaly depends on the inclination
the orthodontic that the canine tooth germ presents. If the angle formed
treatment (patient by the mid-sagittal plane and unerupted canine is less than
aged 10 years). 300, transmigration is unlikely. If the angle is between 300
and 500 unerupted canine may tend to cross the midline.
Because the canine migrated to the contralateral hemi When the angle exceeds 500, crossing the midline becomes
arch, it was not possible to align it in its original position a rule [4, 32].
on the dental arch. Nevertheless, we succeeded to integrate Sharma and Nagpal (2011) suggested that angulation
it between the two mandibular right incisors. However, of long axis of unerupted canine with mid-sagittal plane
an acceptable outcome was gained that allowed us to should always be evaluated in mixed dentition period.
obtain morphological and functional restoration of the An early and timely intervention would lead to better
mandibular dental arch with the conservation of the entire management of the transmigrated canine and hence to
dental system and to achieve a functional occlusion to avoiding the potential complications associated with
ensure optimum evolution of stomatognathic system. transmigrated canine [16].
According to Stafne (1963), the greatest amount of Vichi and Franchi [33] suggested that an 8- to 9-
canine intraosseous movement takes place prior to year-old patient with an excessive mesial inclination of
completion of tooth root development – between the ages the unerupted mandibular permanent canine germ should
of 11- and 14-year-old [24]. Peck (1998) suggested that be kept under observation with periodical panoramic
the intraosseous migration of a canine apparently starts radiographic examinations. If the position of the unerupted
earlier, during the early mixed dentition stage and may mandibular canine is observed to tilt mesially progress-
last many years [25]. If the diagnosis had been made even sively, interceptive measures should be taken. The
later, the transmigrated canine probably would have preventive and interceptive treatment should include
continued to move in the contralateral hemi arch to the extraction of the retained deciduous canine and surgical
premolar and molar region. Joshi (2001) suggested that exposure of the transmigrated canine followed by ortho-
the stage of transmigration will depend on the time of dontic treatment [20, 33]. According to this observation,
diagnosis [4]. Thus, Auluck et al. (2006) and Aktan our study emphasizes the importance of early diagnosis
et al. (2008) reported two cases of extreme transmigrated to correct this abnormality before the tooth migrates too
canines, where the canines were lying horizontally under far from its original place.
1202 Ligia Vaida et al.

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Corresponding author
Mihaela Băciuţ, DMD, MD, PhD, Department of Implantology and Maxillofacial Surgery, “Iuliu Haţieganu” University
of Medicine and Pharmacy, 37 Cardinal Iuliu Hossu Street, 400129 Cluj-Napoca, Romania; Phone/Fax +40264–
450 300, e-mail: mbaciut@yahoo.com

Received: January 17, 2014

Accepted: October 17, 2014