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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 26  |  Issue : 2  |  Page : 128-132

Radiographic localization of impacted maxillary canines: A comparison of methods


1 Department of Oral Medicine and Radiology, I.T.S. Centre for Dental Studies and Research, Muradnagar, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India

Date of Submission31-Jul-2014
Date of Acceptance30-Sep-2014
Date of Web Publication30-Oct-2014

Correspondence Address:
Shruti Garg
A-2/39C, Block - A2, Keshav Puram, Delhi - 110 035
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.143683

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   Abstract 

Objective: The purpose of this study was to determine whether localization is achievable with a single panoramic radiograph. Materials and Methods: A total of 40 patients were studied, in varying age groups and were assessed clinically for impacted or erupted malpositioned maxillary canines. In 20 patients with erupted malposed canines, a panoramic radiograph was compared with the clinical visual method; and in the remaining 20 patients with impacted maxillary canines, a panoramic radiograph was compared with the buccal object rule, for localizing the canine. Results: In our study, the patients were in the age group of 11-52 years, with a mean age of 23.47 ± 8.63 years (SD). Kappa statistics revealed good agreement for localization by using panoramic radiographs when compared to the visual method (value-0.684), and they revealed moderate agreement for localization when using panoramic radiographs, as compared to the buccal object rule (value-0.630). A coefficient correlation for reliability of a panoramic radiograph gave a predictive value of P < 0.0001, thus proving that using panoramic radiography for localizing the object is highly significant. Conclusion: Our study suggested that panoramic radiography is a moderately reliable tool for localizing maxillary impacted canines.

Keywords: Buccal object rule, impacted maxillary canine, panoramic localization


How to cite this article:
Garg S, Raghavan V, Dhingra R. Radiographic localization of impacted maxillary canines: A comparison of methods . J Indian Acad Oral Med Radiol 2014;26:128-32

How to cite this URL:
Garg S, Raghavan V, Dhingra R. Radiographic localization of impacted maxillary canines: A comparison of methods . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2019 Jun 26];26:128-32. Available from: http://www.jiaomr.in/text.asp?2014/26/2/128/143683


   Introduction Top


Impaction is defined as a failure of tooth eruption at its appropriate site in the dental arch, within its normal period of growth. [1] An impacted tooth is one 'whose eruption is considerably delayed, and for which there is clinical or radiographic evidence that further eruption may not take place'. [2]

Localization means determination of the site or place of any process or lesion. [3] The radiographic image is a 2D representation of a 3D object, but for clinical practice it is necessary to derive 3D information. The standard periapical radiograph shows teeth, bone, foreign objects or impacted teeth only in 2D, namely, in superoinferior and anteroposterior relationships. A mediolateral relationship of the objects is not seen.

We performed this study because the maxillary canine has a high incidence of impaction [Table 1] and its position is of clinical significance, as it is regarded as the corner stone of the dental arch, and its role in occlusion during mandibular lateral excursion is equally well known. [6] The purpose of this study was to determine and prove that localization is achievable with a single panoramic radiograph.
Table 1: Table showing the prevalence of impacted maxillary canines, as quoted by different authors

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   Materials and Methods Top


The study group consisted of 40 patients between the age group of 11 and 52 years, of both the genders, with clinically missing and malposed canines; excluding bilaterally impacted canines, rotated contralateral erupted permanent canines, primary dentition, and any arch discrepancies. These subjects reported to the Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand. The patients were clinically examined and checked for any retained deciduous, missing, or erupted malposed maxillary canines, after obtaining an informed consent.

Radiographic assessment has been done by using radiovisiography (RVG) (Make: Sopro) for the buccal object rule and panoramic radiography (Make: Kodak 8000C Panoramic and Cephalometric Unit). As the buccal object rule states that the buccally located object moves in the direction of the x-ray beam, on changing the direction of x-ray beam, the position of the impacted canine can be determined. In this study, to assess the shift of the impacted canine, the incisal tip of the canine has been checked in each radiograph. For panoramic standardization, to ensure that the horizontal magnification is equivalent, the widest mesiodistal dimensions of the mandibular first molars on both sides have been measured using the Kodak dental software and a digital vernier caliper, and compared. If the difference has been found to be greater than 5%, the radiograph was excluded from the study. A basic principle of panoramic localization is that an object placed closer to the film (i.e., farther from x-ray source) throws a smaller shadow than an object located at a greater distance from the film and closer to the x-ray source. Therefore, the objects placed buccally in the patient's mouth appear small in the horizontal plane, as compared to the objects placed palatally.

The widest mesiodistal measurements were made (using the Kodak dental software and a digital vernier calliper) of the displaced tooth on a line perpendicular to its long axis and of the contralateral canine on a line perpendicular to its long axis [Figure 1] and [Figure 2]. The measurements were subjected to statistical analysis.
Figure 1: The widest mesiodistal dimension of an impacted (9.3) and erupted (8.9) contralateral canine (measured by Kodak dental software)

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Figure 2: The widest mesiodistal dimension of an erupted malposed (9.7) and erupted (7.6) contralateral canine (measured by Kodak dental software)

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   Results Top


In the present study, in the total number of 40 patients, 20 (50%) were male and 20 (50%) were female [Table 2], [Graph 1]. [Additional file 1] Maximum cases (50%) were found to be in the age group of 21-30 years, with a mean age of 23.47 ± 8.63 years (SD) [Table 3], [Graph 2].[Additional file 2]{ Table 2}
Table 3: Age-wise distribution of cases (n = 40)

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Of these 40 patients, location in 20 cases was confirmed by the buccal object rule and location in the other 20 cases was confirmed by the visual method, out of which 22 patients had palatally placed canines, 17 had labially placed canines and one patient's canine was located in the same plane as that of the other teeth with P = 0.0005, calculated through the chi square test [Table 4], [Graph 3]. [Additional file 3]
Table 4: Location of canines as viewed by two different confirmatory methods

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On comparing the buccal object rule and panoramic localization techniques in these patients, it was found that two patients showed labial positioning according to both the techniques, 17 showed palatal positioning according to both techniques; and in one patient, the position of the impacted maxillary canine was found to be palatal according to panoramic localization, but in the same plane, according to the buccal object rule. According to buccal object rule, the position of the impacted maxillary canine was found to be labial in 10% of the cases, palatal in 85%, and in the same plane in 5%; and according to the panoramic localization technique it was found to be labial in 10% of the cases, palatal in 90%, and in the same plane in 0% of the cases. The weighted Kappa value (0.63) for comparison of the buccal object rule and panoramic localization technique showed moderate agreement, with a standard error of 0.286, and 95% confidence interval (CI), ranging from 0.0682 to 1.000 [Table 5].
Table 5: Comparison of the buccal object rule and panoramic localization technique in one group

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On comparing the clinical and visual method and the panoramic localization technique in these patients, it was found that 12 patients showed labial positioning according to both techniques, five showed palatal positioning according to both techniques, and in one patient, the position of the malposed maxillary canine was found to be labial according to the visual method, but in the same plane according to the panoramic localization. In two patients, the panoramic localization technique showed palatal positioning, but when viewed clinically the malposed canine was present labially. According to the visual method, the position of the impacted maxillary canine was found to be labial in 75% of the cases, palatal in 25%, and in the same plane in 0%; and according to the panoramic localization technique it was found to be labial in 60% of the cases, palatal in 35%, and in the same plane in 5% of the cases. The weighted Kappa value (0.684) for comparison of the visual method and panoramic localization technique showed good agreement, with a standard error of 0.154 and 95% CI ranging from 0.382 to 0.986 [Table 6].
Table 6: Comparison of the visual method and panoramic localization technique in one group

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Reliability between the buccal object rule and panoramic localization technique was calculated by using the correlation coefficient, which was seen to be 0.7127, with a 95% CI of 0.5157 to 0.8381. There was a statistically significant correlation between the localization techniques with P < 0.0001 [Table 7].
Table 7: Correlation coefficient for reliability of localization techniques

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   Discussion Top


The position of canine is of clinical significance, as it is regarded as the corner stone of the dental arch and its role in occlusion during mandibular lateral excursion is equally well known. [7] Several etiological factors for canine impactions have been proposed in literature: Localized, systemic or genetic. The incidence of canine impaction in the maxilla is more than twice that in the mandible, as reported in literature. [8] There are two major theories associated with palatally displaced maxillary canines: The guidance theory and the genetic theory. [8],[9],[10],[11]

On account of the denser palatal bone and thicker palatal mucosa, as well as a more horizontal position, palatally displaced cuspids rarely erupted. [10] In our study, 55% of the maxillary canines were found to be placed palatally. The result was consistent with the study conducted by Nordenram and Stromberg. [6],[12] Fournier et al., and Gaulis and Joho [6] reported 75 and 66% palatally placed canines, respectively. If labially impacted cuspids erupted they did so vertically, buccally, and higher in the alveolus. [11] In this study, 45% of maxillary canines were found to be placed labially.

Maxillary impacted canines in this study were found to be in a 1:1 ratio in males (50%) and females (50%). However, in literature, they were twice as common in females (1.17%) than in males (0.51%). [13],[14]

In our study, the correct prediction of a palatal or labial canine position, using panoramic localization, was 90%. This result was in accordance with the study by Bhuvaneshwari et al., [13] who reported 85.07%. Previous studies showed that the accuracy of diagnosis of the same was 80 to 90%. [3] Also, according to Wolf and Mattila, the labiopalatal position of approximately 90% of all impactions could be determined accurately. [3],[13]


   Conclusion Top


Methods used for object localization include, the parallax method and the right-angle technique. Radiation exposure with these techniques is much higher, as two or more radiographs are required. Multiple exposures for localization of objects should be avoided as complex damage to the DNA, the basis for cancer formation, may occur with x-rays. A panoramic radiograph is a screening radiograph that is routinely advised in dental practice, as it provides information about the entire dentition in one radiograph. Various studies have been conducted to evaluate the reliability of the panoramic radiograph in localization of the maxillary impacted canine.

The present study was conducted to prove and determine that localization is feasible with a single panoramic radiograph. All patients in the study were subjected to panoramic radiography, which was compared with the visual method in cases where erupted malposed canines were seen, and the buccal object rule was used in cases where the maxillary canine was impacted. The correct prediction of the palatal or labial canine position using panoramic localization came to 90%, thus, suggesting that the panoramic radiograph is moderately reliable in localizing the maxillary impacted canine.

 
   References Top

1.
Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone-beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:91-8.  Back to cited text no. 1
    
2.
Mason C, Papadakou P, Roberts GJ. The radiographic localization of impacted maxillary canines: A comparison of methods. Eur J Orthod 2001;23:25-34.  Back to cited text no. 2
    
3.
Nagpal A, Pai KM, Setty S, Sharma G. Localization of impacted maxillary canines using panoramic radiography. J Oral Sci 2009;51:37-45.  Back to cited text no. 3
    
4.
Chaushu S, Chaushu G, Becker A. The use of panoramic radiographs to localize displaced maxillary canines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:511-6.  Back to cited text no. 4
    
5.
Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol 2004;33:164-9.  Back to cited text no. 5
    
6.
Gavel V, Dermaut L. The effect of tooth position on the image of unerupted canines on panoramic radiographs. Eur J Orthod 1999;21:551-60.  Back to cited text no. 6
    
7.
Sudhakar S, Patil K, Mahima VG. Localization of impacted permanent maxillary canine using single panoramic radiograph. Indian J Dent Res 2009;20:340-5.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Bedoya MM, Park JH. A review of the diagnosis and management of impacted maxillary canines. J Am Dent Assoc 2009;140:1485-93.  Back to cited text no. 8
    
9.
Litsas G, Acar A. A review of early displaced maxillary canines: Etiology, diagnosis and interceptive treatment. Open Dent J 2011;5:39-47.  Back to cited text no. 9
    
10.
Richardson G, Russell KA. A review of impacted permanent maxillary cuspids - diagnosis and prevention. J Can Dent Assoc 2000;66:497-501.  Back to cited text no. 10
    
11.
Peck S, Peck L, Kataja M. The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod 1994;64:249-56.  Back to cited text no. 11
    
12.
Nordenram A, Strömberg C. Positional variations of the impacted upper canine: A clinical and radiologic study. Oral Surg Oral Med Oral Pathol 1966;22:711-4.  Back to cited text no. 12
    
13.
Bhuvaneshwari S, Ahmed J, Singh MP. Use of panoramic radiograph as a single radiographic technique to localize impacted maxillary canine. J Cancer Sci Ther 2010;2:163-5.  Back to cited text no. 13
    
14.
Katsnelson A, Flick WG, Susarla S, Tartakovsky JV, Miloro M. Use of panoramic x-ray to determine position of impacted maxillary canines. J Oral Maxillofac Surg 2010;68:996-1000.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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