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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 12
| Issue : 1 | Page : 5 |
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Normal pre-eruptive inclinations of maxillary canine, lateral incisor, and first premolar in children aged 6–14 years
Santosh K Goje1, Bhavna Dave2
1 Department of Orthodontics and Dentofacial Orthopedics, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat, India
2 Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat, India
| Date of Submission | 08-May-2022 |
| Date of Decision | 18-Jul-2022 |
| Date of Acceptance | 22-Aug-2022 |
| Date of Web Publication | 18-Mar-2023 |
Correspondence Address:
Santosh K Goje
Professor and HOD, Department of Orthodontics and Dentofacial Orthopedics, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat – 391 760
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jos.jos_40_22
BACKGROUND: Maxillary canine is the second most common tooth that gets impacted after III molars. Early pre-eruptive inclination changes of first premolar and its associative changes with canine inclination are an important factor that predicts the fate of maxillary canines. Hence, a cross-sectional study was planned to evaluate the normal pre-eruptive mesiodistal inclinations of maxillary permanent canine, first premolar, and lateral incisor in children aged 6–14 years using orthopantomogram.
MATERIALS AND METHODS: The total number of participants was 296. Each group of boys and girls consisted of 37 participants in each of the age groups 6–8 years, 8–10 years, 10–12 years, and 13–14 years, making up a total of 148 boys and 148 girls. Routine clinical examination was conducted, and orthopantomograph was taken for radiographic examination. Orthopantomographs of all these participants were collected. Inclination of lateral incisor, inclination of canine, and inclination of premolar with midline were measured on the orthopantomogram. Also, the angles between the canine with lateral incisor and canine with first premolar were measured. Pearson correlation was also evaluated between the movement of canine with lateral incisor and canine with first premolar.
RESULTS: All the mean angles related to lateral incisor, canine, and first premolar with midline were recorded. Also, the angles between the canine with lateral incisor and the canine with first premolar were recorded. The movements between lateral incisor, canine, and first premolar were moderately correlated from 6 to 12 years of age.
CONCLUSION: The eruption of canine from the floor of the nose till it erupts has its synchronized influence on the lateral incisor and the first premolar.
Keywords: Guidance theory, maxillary canine impaction, normal pre-eruptive canine angles, orthopantomogram, ugly duckling stage
How to cite this article:
Goje SK, Dave B. Normal pre-eruptive inclinations of maxillary canine, lateral incisor, and first premolar in children aged 6–14 years. J Orthodont Sci 2023;12:5 |
How to cite this URL:
Goje SK, Dave B. Normal pre-eruptive inclinations of maxillary canine, lateral incisor, and first premolar in children aged 6–14 years. J Orthodont Sci [serial online] 2023 [cited 2023 Oct 3];12:5. Available from: https://www.jorthodsci.org/text.asp?2023/12/1/5/371965 |
| Introduction | |  |
The maxillary canine is the second most common tooth that gets impacted after III molars. The prevalence of maxillary canine impaction is 1.7% in the general population.[1] The causes of this high prevalence of impaction are its extended development period and the long tortuous path it travels before it erupts in the oral cavity.[2] Females show a strong prevalence over males for maxillary canine impactions.[3] Managing the maxillary canine impaction is a challenging problem in the practice of orthodontics. The initiation of mineralization of the crown of the canine begins between 4 and 12 months of age and is completed at about 6–7 years. The canine is high over the deciduous canine at age 8, and from there, it gets inclined in mesial and occlusal directions till the level of the distal aspect of the root of the lateral incisor. The erupting canine is gradually upright to a more vertical position and is guided by the lateral incisor root, till it is fully erupted at mean ages of 10–12 years for girls and 11–13 years for boys.[4]
Maxillary canine impactions have been found on the palate in 85% of the cases and on the buccal in 15% of the cases.[5] It is estimated that 8% of all patients with maxillary impacted canines have bilateral impaction.[6] The local causes of palatally impacted maxillary canines are the congenital absence of lateral incisor or premolars or anomalies of the lateral incisor.[5] Incisor root resorption is commonly seen in a maxillary impacted tooth, which is asymptomatic and usually diagnosed late in relation to their age and severity of resorption.[7] The ability to distinguish the physiological inclination of the permanent lateral incisor, canine,[8] and first premolar from an inclination indicating a pathological eruption pattern of the canine would be particularly relevant for clinicians and requires an understanding of the normal eruptive pattern. Interceptive management of maxillary canine impaction includes extraction of deciduous canines, in a combination of creating space in the dental arch by distalization[9] or extraction of a maxillary deciduous first molar or expanding the dental arch.[10] When interceptive treatment fails, surgical exposure of the impacted canine is essential, requiring orthodontic interventions for bringing the canine into the oral cavity.[11] As the patient grows older, the period and difficulty of treatment also increase.[12]
Interceptive treatment with extraction of both deciduous maxillary canine and first molar (double extraction) is found to be more beneficial than the extraction of only deciduous maxillary canine.[13],[14] These double extractions lead to a significant change in inclination of the first premolar which, in turn, uprights the canine, conforms to the association that changes in the inclination of the first premolar will affect the inclination of the canine and will prevent impactions.[15] Therefore, early pre-eruptive inclination changes of the first premolar and its associative changes with canine inclination form an important factor that predicts the fate of maxillary canines. To date, there is only one retrospective study[16] that has tried to correlate normal maxillary first premolar eruption pattern or its relationship with the canine eruption pattern. Even this study has evaluated the inclination of the first premolar, canine, and lateral incisors at 8 and 10 years only. Hence, there is a need to evaluate the early pre-eruptive inclination changes and their association with canine inclinations till the canine erupts in the oral cavity. Three-dimensional imaging would be elective in evaluating the position of the incisor in the three planes of space, as well as in assessing whether any root resorption has taken place, but the costs (from an economic and, more importantly, a biological point of view) are still prohibitive in many practices.[17],[18],[19] Hence, a cross-sectional study has been planned to evaluate the normal pre-eruptive mesiodistal inclinations of maxillary permanent canine, first premolar, and lateral incisor in children of age 6–14 years using orthopantomogram.
Hypothesis: There is an association of pre-eruptive inclination changes of maxillary first premolar with inclination changes of maxillary canine. This leads to the hypothesis that any abnormal pre-eruptive inclination of the maxillary first premolar will lead to eruptive problems of the maxillary canine. Hence, the study is planned to evaluate the normal pre-eruptive inclination changes of the maxillary permanent canine, lateral incisor, and the first premolar in children aged 6–14 years.
Aim
The study aims to evaluate the normal pre-eruptive inclination changes of maxillary canine, lateral incisor, and first premolar in children aged 6–14 years according to their chronological age using orthopantomogram.
| Materials and Methods | | |
The study was started after taking the ethics approval from Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC). The participants of this study were children aged 6–14 years, who had maxillary deciduous canine and maxillary first permanent molar in their place. The total number of participants was 296. The participants were selected in such a manner that each group consisted of equal number of boys and girls. Each group of boys and girls consisted of 37 participants in each of the age groups 6–8 years, 8–10 years, 10–12 years, and 13–14 years, making up a total o f 148 boys and 148 girls. The sample size was calculated according to the study of Alessandri Bonetti.[8] A sample size of 250 achieves a power of 80 to detect an effect size(W) of 0.2 using 200 of freedom with Chi-square test, with a significance level (alpha) of 0.05.
All these participants had come for a routine dental examination for their age. A routine clinical examination was conducted and an orthopantomograph was taken for radiographic examination. Orthopantomographs of all these participants were collected. Written informed consent was obtained from the participants and their parents after explaining the study in detail. Those with any sign of early predictors of probable impaction[20] of canine in the future in the clinical and radiographic examination were excluded. Also, those with previous orthodontic treatment, history of traumatic injury, agenesis of any tooth, odontomas, cysts, supernumerary teeth, small or peg-shaped lateral incisor, any abnormality of the first premolar, cleft lip and palate, any craniofacial syndromes, ankylosis of deciduous canine, premature exfoliation of deciduous canine with drifting of adjacent teeth, and loss of space of permanent canine before its eruption were all excluded.
All these orthopantomographs were digitized in dolphin cephalometric software (11.9), and the following parameters were analyzed.
The inclination of lateral incisor: It is the angle formed by using the midline constructed according to Power and Short[21] and the long axis of the lateral incisor [Figure 1].
The inclination of canine: It is the inclination of the long axis of the canine to the midline[21] [Figure 2].
The inclination of premolar: It is the inclination of the long axis of the first premolar to the midline[15] [Figure 3].
An angle formed by canine and lateral incisor: This is the angle formed by the intersection between the long axis of the canine and the long axis of the lateral incisor[22] [Figure 4].
An angle formed by canine and first premolar: This is the angle formed by the intersection between the long axis of the canine and the long axis of the first premolar [Figure 5].
Mesio-distal position of the tooth: The location of the canine cusp tip and first premolar cusp tip is assessed according to the sector analysis[23] [Figure 6].
Statistical analysis
The means of the inclination of the lateral incisor, canine, and premolar with midline were calculated in all the groups. Also, the means of angular values between canine and lateral incisor and between canine and premolar were calculated. Significant differences between the inclinations of lateral incisor with the midline in all the groups, the inclination of canine with the midline in all the groups, and the inclination of premolar with the midline in all the groups were evaluated with the analysis of variance (ANOVA) test. Significant differences between the angle of canine and lateral incisor in all the groups and between the canine and the first premolar in all the groups were evaluated by ANOVA test. Pearson correlation was evaluated between the angles of lateral incisor with midline and canine with midline in all the groups. Similarly, Pearson correlation was evaluated between the angles of canine with midline and first premolar with midline in all the groups. Pearson correlation was evaluated between the angle formed by canine with lateral incisor and canine with the first premolar in all the groups. All these were evaluated in boys and girls.
| Results | | |
Two hundred and ninety-six orthopantomographs were obtained from the 296 children with age ranging from 6 to 14 years. Of them, 148 were boys and 148 were girls. There were 37 boys in each of the age groups 6–8 years, 8–10 years, 10–12 years, and 12–14 years. Similarly, there were 37 girls in in each of the age groups 6–8 years, 8–10 years, 10–12 years, and 12–14 years.
All the measurements were recorded twice with an interval of 3 weeks by the same trained examiner. The intraclass correlation coefficient between the two measurements was 0.97. There was no difference between right- and left-side measurements. For analysis, value from only one side was considered.
There was a significant difference between the mean ages of the four groups in boys as well as girls [Table 1]. | Table 1: Mean age of boys and girls in various groups with a statistical significance of P=0.05 by ANOVA test
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The mean angulations of the lateral incisor, canine, and premolar with the midline in all the groups of boys and girls were significantly different in different age groups [Table 2]. The mean angulations of lateral incisors with canine and first premolar with canine were significantly different in all the groups of boys and girls [Table 3]. | Table 2: Mean angle of long axis of maxillary permanent lateral incisor, maxillary erupting canine, and maxillary erupting first premolar with midline with a statistical significance of P=0.05 by ANOVA test in boys and girls
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 | Table 3: Mean angulations of lateral incisor with canine and first premolar with canine with a statistical significance of P=0.05 by ANOVA test in boys and girls
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The correlation between movement of lateral incisor with the midline angulations and canine with the midline angulations was moderate and highly significant for all the age groups of boys and girls, except in the age group of 12–14 years. The correlation between movement of the first premolar with the midline angulations and canine with the midline angulations was also moderate and highly significant in both boys and girls, except in the age group of 12–14 years [Table 4]. | Table 4: Pearson correlation between angles of lateral incisor with midline and canine with midline with a statistical significance of P=0.05 by unpaired t-test in boys and girl
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The correlation between the angulations of canine and lateral incisor with canine and first premolar was moderate and highly significant during 6–8 and 8–10 years of age in boys and girls, but was weak and not significant during 11–12 and 12–14 years of age in boys and girls [Table 5]. | Table 5: Pearson correlation between the angulations of lateral incisor with canine and canine with first premolar with a statistical significance of P=0.05 by unpaired t-test
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The cusp tip of erupting canine is in sector 2 during the age of 6–8 and 8–10 years in both boys and girls. During the age of 10–12 years, the cusp tip of the erupting canine slowly shifts from sector 2 to sector 1 in both boys and girls. The cusp tip of erupting first premolar is always in sector 0 in all the groups in both boys and girls.
| Discussion | | |
Several studies have reported that there is a relationship between the movement of canine and lateral incisor when the canine is erupting.[24],[25],[26],[27] However, till now, no study has given the angular values of the erupting canine with midline, canine with lateral incisor, and canine with premolar at various age groups, till the canine erupts in the oral cavity. The ideal design for this type of study will be longitudinal, following the sample participants right from 6 to 12 years, taking serial panoramic radiographs. In such a type of longitudinal study, the attrition rate of the sample might be high and ethics may not permit exposing children to X-rays for the study. Hence, a cross-sectional study was planned on orthopantomographs collected from those individuals who came for a routine dental examination.
Most of the studies[15],[26],[27],[28] which evaluated the eruptive movement of canine, first premolar, and lateral incisor are retrospective, and no study has evaluated the normal pre-eruptive angulations of the canine, lateral incisor, and first premolar during 6–12 years of age. In this study, orthopantomograph, which is a two-dimensional image of a three-dimensional object, was used. Orthopantomographs were chosen for this study because these are the common diagnostic radiographs that will be taken for screening purposes, especially in children who come for a routine dental examination. As soon as we see the erupting canine on the orthopantomograph, it could be predicted whether the canine is erupting normally or abnormally at that particular stage. Moreover, the radiation exposure for orthopantomograph is less when compared to 3D imaging.
In this study, the angulations of the lateral incisor, erupting canine, and the first premolar with the midline were evaluated. Also, the angle between the lateral incisor with canine and the first premolar with canine was evaluated for boys and girls aged from 6 to 12 years, which is the period of eruption of canine from the floor of the nose till it comes out in the oral cavity. Between the ages of 6 and 8 years, the canine crown gets calcified and hits the distal surface of the root of the lateral incisor, making the root of the lateral incisor move mesially and crown distally, thus creating a space between the crowns of the lateral incisor and the central incisors, which is known as ugly duckling stage. The angular values in this period were represented by negative symbols because canine and lateral incisors were inclined opposite to each other.
Shin et al.[28] also stated that the angle between the canine and the lateral incisor in a normal erupting canine will first increase and then decrease as the canine approaches the cervical area of the lateral incisor. This results in the ugly duckling stage and will self-correct after the canine has fully erupted into the oral cavity. These angular values in impacted canines will not follow any pattern and will remarkably deviate from the normal angular values between the erupting canine and the lateral incisor. They also stated that the three best parameters that discriminate impacted canine and normally erupting canine are the angle between the erupting canine and the first premolar, canine cusp tip to midline distance, and canine cusp tip to maxillary occlusal plane distance. But the predicting capability is weak, unless they are used in the regression formula given by them.
It has been observed in this study that canine has an influence on both lateral incisor and first premolar during its erupting phase. The movements of the lateral incisor and first premolar will appear as though they are pre-programmed with the movement of the erupting canine. The movement of the lateral incisor with canine and the movement of the first premolar with canine were moderately correlated in the age groups of 6–8, 8–10, and 10–12 years and were highly significant in both boys and girls. But in the group of 12–14 years of age, this correlation was very weak and was not significant in both boys and girls. This might be because the canine at the age of 12–14 years might have already erupted in the oral cavity and may not have its influence on the lateral incisor and first premolar.
Alessandri Bonetti et al.[15] stated that extraction of both deciduous canine and deciduous first molar will spontaneously upright the erupting first premolar which, in turn, will have an influence on uprighting the erupting canine, thus preventing impaction of the canine. This is in agreement with our study which showed that canine and premolar movements correlated with each other during their eruption.
The drawback of this study is its cross-sectional design, which was followed as the ethics committee might not permit a longitudinal design that needs exposure of children to radiographs for the study. The other reason to choose a cross-sectional design is the attrition of the sample, as it may take a prolonged period for a longitudinal study. However, the ideal design for this type of study is a longitudinal study. A longitudinal study with a larger sample size may provide more accurate results.
| Conclusions | | |
Eruption of the canine from the floor of the nose till it erupts has its synchronized influence on the lateral incisor and first premolar. The angulations of the lateral incisor, canine, and first premolar were evaluated. There was a moderate correlation between the movement of the canine with lateral incisor and first premolar from 6 to 12 years of age.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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