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 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 15

Frequency and pattern of impacted Canines in Al-Madinah, Saudi Arabia: A cross-sectional radiographic study

1 Department of Orthodontics, College of Dentistry and University Dental Hospital, Taibah University, Saudi Arabia
2 Dental Intern, University Dental Hospital, Taibah University, Saudi Arabia

Date of Submission22-Nov-2021
Date of Decision08-Jan-2022
Date of Acceptance11-Jan-2022
Date of Web Publication04-May-2022

Correspondence Address:
Asim Abdulrahman Almarhoumi
Taibah University Dental College and Hospital, Prince Abdulmajeed Street, Medina - 42313
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jos.jos_188_21

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OBJECTIVES: Impacted canine (IC) is a dental anomaly that varies in its frequency according to the population of interest. The aim of this study is to investigate the frequency and distribution pattern of maxillary ICs (MxIC) and mandibular ICs (MnIC) in the population of Al-Madinah, Saudi Arabia.
MATERIALS AND METHODS: A cross-sectional retrospective study of all patients attended Taibah University Dental Hospital, Madinah, Saudi Arabia. Inclusion criteria were individuals aged 15 years and older and no history of orthodontic treatment or craniofacial syndromes. Patients with incomplete dental records or missing/distorted Orthopantomograph (OPG) were excluded. All OPGs were taken using standardized equipment. Data were explored for frequency and pattern of canine impaction both in the maxilla and the mandible and statistically tested to detect significant differences.
RESULTS: A total of 7466 individuals fulfilled the inclusion criteria with mean age of 37.43 ± 14.5 years. Of the total sample, 173 individuals had at least one IC. MxIC alone occurred in 86.71% of the cases, while MnIC occurred in 8.67%. The remaining 4.62% had at least one IC in each jaw. Unilateral IC occurred in 89.2% of the cases with left-side predominance in the maxilla.
CONCLUSION: In this sample, the frequency of MxIC was 2.1% and MnIC was 0.3%. Almost equal distribution of IC occurred between females and males (IC Odds ratio F:M 1:1.08). Further studies are required to investigate the potential association of IC incidence with other predictor variables.

Keywords: Canine impaction, frequency, orthodontics, prevalence, Saudi Arabia

How to cite this article:
Almarhoumi AA, Okashah YA, Alrehaili MA, Alrehaili KN. Frequency and pattern of impacted Canines in Al-Madinah, Saudi Arabia: A cross-sectional radiographic study. J Orthodont Sci 2022;11:15

How to cite this URL:
Almarhoumi AA, Okashah YA, Alrehaili MA, Alrehaili KN. Frequency and pattern of impacted Canines in Al-Madinah, Saudi Arabia: A cross-sectional radiographic study. J Orthodont Sci [serial online] 2022 [cited 2023 May 31];11:15. Available from: https://www.jorthodsci.org/text.asp?2022/11/1/15/344731

  Introduction Top

Tooth eruption is controlled by complex multifactorial genetic and environmental interaction. Hence, aberrations in tooth eruption process such as early, delayed, or failure of eruption can occur.[1] Tooth impaction is one of the most common dental anomalies. When a tooth fails to erupt at the appropriate developmental timing due to physical barrier, it is considered as an impacted tooth.[2] Maxillary canine (cuspid) is the tooth most prone to impaction following third molars.[3] Canines have an important role in the esthetics, function, and occlusion protection.[4] The sequelae of impacted canines (ICs) include ectopic position and transmigration, dentigerous cyst formation, internal and external root resorption of the impacted canine or the adjacent teeth, and loss of arch length and facial alar support.[5] Therefore, it could be argued that canine impaction could have detrimental influence on the stomatognathic system.

Several local and systemic factors could lead to the etiology of canine impaction such as crowding, congenital syndromes, and lateral incisors anomalies.[6] Some of the impaction occur due to genetics reasons, which are as follows: absence or misshape lateral incisor, abnormal path of eruption, presence of supernumerary teeth, hypodontia, and aplasia. Also, canine impaction is found in some conditions such as cleft lip and/or palate, craniofacial syndromes, malnutrition, anemia, and accompanying certain syndromes such as cleidocranial dysplasia, achondrodysplasia, progeria, and Downs syndrome.[7]

Canine impaction is usually asymptomatic, so it is often diagnosed by coincidence during routine check-ups or for any other dental reasons. For evaluation of the presence, position, and pathology related to the IC, different radiographic modalities are utilized such as intra-oral periapical radiographs, occlusal radiographs, orthopantomograms (OPG), cone beam computed tomography, and computed tomography.[8]

According to the literature, the prevalence of IC ranged from 0.8% to 8% based on the populations or ethnicities studied.[9],[10],[11] This wide range necessitates studying and reporting the frequency of IC for each population specifically for better demographic understanding and effective local health-resource allocation and management. In Saudi Arabia, reports of IC prevalence varied according to geographic regions and the population within. It ranged from as little as 1.44% to 10.1%.[12],[13] This wide range is attributed to the sampling size, characteristics, and methodologies used for IC detection. Nevertheless, data still lacking regarding maxillary and mandibular ICs (MxIC and MnIC) frequencies from other geographic parts including this region where the study was conducted. Exploration of IC frequency specifically for this region would not only just be beneficial for better local health-resource allocation within the region but also to plot the findings of this study against previously reported frequencies in Saudi Arabia in order to reduce the wide-range bias of IC within the country.

Therefore, the aim for this study is to investigate the frequency and distribution pattern of MxIC and MnIC according to sex in the population of Al-Madinah Region, Saudi Arabia.

  Materials and Methods Top

A cross-sectional retrospective radiographic study was carried out to assess the frequency of MxIC and MnIC in a hospital-based setting in Al-Madinah, Saudi Arabia.

Ethical approval was granted from the relevant institution. The study has been conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013). OPG images of all patients from January 2014 to December 2018 were evaluated. Inclusion criteria were patients who are 15 years old and above and patients with no previous history of orthodontic treatment and no craniofacial syndromes. Exclusion criteria were poor quality and distorted OPGs, patients who had previous orthodontic therapy, and patients with history of lateral incisor or premolars extraction to minimize the possibility of selection bias.

Pattern and distribution of MxIC and MnIC was assessed based on sex, location of the jaw, and side of impaction. All OPGs obtained were taken with standardized equipment and specification (KODAK 9000 C 3D, Carestream Health, NY, USA. With a magnification factor of 1.14).

Statistical analysis

Data were processed via SPSS, version 26.0 (IBM Corp., NY, USA). Descriptive and analytical statistical tests were conducted. Sex differences were tested using Student's Independent sample t-test. Nominal data was analyzed by Chi square with post hoc Bonferroni adjustments and Fisher's exact test. Statistical significance was determined when P value < 0.05.

  Results Top

A total of 7466 patients fulfilled the inclusion criteria, of which, 3651 were females and 3815 were males. The mean age was 37.43 years old (SD 14.5). Of the total sample, 173 patients had at least one IC (2.3%). Female to male ratio was 1:1.08 with no statistically significant difference detected. Full sample descriptive statistics is found in [Table 1].
Table 1: Descriptive statistics according to sex and distribution of impacted canines in total (IC), maxillary impaction (MxIC), and mandibular impaction (MnIC). (*) denotes cases who had both MxIC and MnIC

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Within IC group, 86.71% had IC in the maxilla alone and 8.67% had mandibular canine impaction alone. The percentage of the sample who had at least 1 IC in each jaw was 4.62% [Figure 1].
Figure 1: Distribution of cases based on jaw location of impacted canines (IC)

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Among the MxIC group, bilateral impaction occurred in 10.8% of the cases. Females exhibited higher bilateral impaction than males, 64.7% and 35.3% respectively. In the mandible, within the MnIC group, bilateral impactions were relatively higher than the opposite arch (17.4%) with 100% occurrence in males only. However, difference in impaction distribution was not statistically significant according to sex, location, and side of the jaw. Full distribution details are found in [Table 2].
Table 2: Location and pattern of impaction distribution. Between sex comparison using Pearson Chi-squared test

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  Discussion Top

Frequency of impacted canines

IC is a product of complex interactions between polygenetic and environmental factors.[14],[15] Hence, the incidence of IC varies across different populations and ethnicities. The frequency of MxIC in this study was 2.1%. Which is in cohort with the range in the orthodontic literature from European populations (0.8% to 2.8%).[2],[9],[16]

In Saudi Arabia, the prevalence of MxIC ranged from as little as 1.44% to 10.1% based on geographic region and population of interest.[12],[13],[17],[18],[19],[20] In this study, on hospital-based population in Madinah Region, the frequency of MxIC fell within the lower side of that range (2.1%). Similar frequencies were found in Abha (1.44%),[12] Jazan (1.89%),[17] Jeddah (3.3%),[18] and Najran (5.35%).[19] The highest frequency of MxIC was reported from Riyadh city: (10.1%)[20] and (7.5%).[13] However, their sample size was relatively small and was obtained from orthodontic patients exclusively.

Across gender, females had slightly less MxIC than males (F:M ratio 1:1.08), but no statistically significant difference was found. This contrasted with previous reports which found female predominance in MxIC (F:M ratio ranged from 1.45:1 to 2.1:1).[17],[20] These wide variations in range could be attributed to disparities in sample size, distribution, characteristics, selection criteria, and different study methodologies.

In the mandible, the frequency of MnIC was found to be 0.1%, which is in cohort with previous reports from Hong Kong (0.07%)[11] and Germany (0.1%).[3] Frequencies of MnIC was slightly higher in the United States (0.22%)[4] and Jizan, Saudi Arabia (0.4%)[17] with ratio of 10:1 MxIC to MnIC, which is comparable to our findings of 7:1 MxIC to MnIC in this sample of Madinah residents. Unlike upper canines, failure of lower canine eruption is mostly due to the presence of physical impediments like crowding and drifting of adjacent teeth.[21] Nevertheless, our findings agree with previous reports regarding the rarity of MnIC compared with MxIC, although females had lower MnIC incidence relative to their male counterparts (F:M ratio 1:1.55). However, no statistically significant difference was detected across gender.

Distribution pattern of impacted canines

Single unilateral MxIC occurred in most cases (89.2%). A finding agrees with previous orthodontic literature regarding unilateral impaction being more prevalent than the bilateral.[13] Some studies reported equal unilateral left and right MxIC distribution.[17] Other studies found left-side impaction more frequent than the right regardless of patient's sex.[13],[19],[22],[23] The finding in this study conforms with the latter. However, no plausible explanation was given regarding left-side impaction predominance in the literature. Females exhibited almost double Bilateral MxIC compared with males (Odds Ratio 2.08), a figure similar to previous reports in the orthodontic literature.[2],[16],[24] The relatively higher bilateral MxIC in females could be attributed to the differences in growth pattern between the sexes as stated by Melha.[25] Other local, systemic, and genetic factors that may be involved in MxIC need to be explored in the scope of sex-related differences.

On the contrary, bilateral MnIC occurred exclusively in males in this cohort. Due to rarity of MnIC in the population, this figure could be purely coincidental in this sample as no statistical significance difference was detected between genders. A study in Turkey reported slightly higher MnIC frequency in males compared with females (F:M ratio 1:1.15); however, no detailed distribution regarding sex and pattern of MnIC was provided.[26] According to Peck, bilateral MnIC is suggestive of genetic determinant.[14] Other authors suggested different etiological factors for MnIC such as ectopic position of tooth germ, early or delayed loss of primary canine, space discrepancies, and abnormal crown morphology.[27],[28],[29] However, the etiology and exact mechanism for MnIC remains unclear.

Strength and limitations

To the best of our knowledge, this study included the largest sample size that is not exclusive to orthodontic patients only, in addition to wider age range and equal gender distribution compared with previous reports from Saudi Arabia. Nonetheless, this study has an inherent bias in sample collection as it was collected retrospectively from a single hospital that represents only one geographic region in Saudi Arabia. Only patients with logged dental records including OPGs were included in the study. Labio-lingual positions of ICs were not evaluated in this study because the supporting diagnostic aids such as radiographs and/or detailed orthodontic records were not readily available for most patients. It would be unethical to expose individuals to unnecessary radiation just to assess the canine position with no intention for treatment. Also, obtaining a representative sample of the population would impose several ethical and financial challenges. Therefore, caution should be exercised when interpreting and generalizing the results of this study.

  Conclusion Top

The frequency of MxIC and MnIC were 2.1% and 0.3%, respectively, in the population of Al-Madinah, Saudi Arabia. Unilateral IC predominated bilateral impaction both in the maxilla and the mandible with most incidences occurring in the left-side of the maxilla. Overall, both genders exhibited almost equal distribution of IC with slight male predominance in the mandibular canine impaction.

Future scope/clinical significance

Further studies are required to investigate the correlation between IC and other predictor etiological factors.

Data availability statement

The data set used in this study is available on request from Asim A. Almarhoumi (email address: [email protected]).

Ethical policy and institutional review board statement

Ethical approval was granted from the Research Ethics Committee, College of Dentistry, Taibah University (approval no. TUCDREC/08022021/AAAlmarhoumi). All the procedures have been performed as per the ethical guidelines laid down by Declaration of Helsinki (2013).

Declaration of patient consent

All the procedures have been performed as per the ethical guidelines laid down by Declaration of Helsinki.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

List of Abbreviations

IC: Impacted Canine; MnIC: Mandibular Impacted Canine; MxIC: Maxillary Impacted Canine; OPG: Orthopantomograph.

  References Top

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  [Figure 1]

  [Table 1], [Table 2]


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