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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 14-22

The effect of displaced canine on the dentoskeletal and soft tissue development of the face: A cephalometric study


Department of Orthodontics and Dentofacial Orthopedics, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India

Date of Web Publication27-Feb-2018

Correspondence Address:
Dr. Suruchi Singh
Department of Orthodontics and Dentofacial Orthopedics, Sri Aurobindo College of Dentistry, Indore Ujjain State Highway, Near MR 10 Crossing, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijor.ijor_32_17

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  Abstract 

Introduction: To analyze the skeletal features of patients with maxillary canine impaction.
Materials and Methods: Pretreatment lateral cephalograms of 30 patients in buccally displaced canine group (BDCG), 15 in palatally displaced canine group (PDCG), 30 in impacted canine group (ICG), and 50 in control reference sample (control group [CG]) were used to analyze the selected dentoskeletal characteristics. One-way analysis of variance was used to identify the differences in angles among the four groups (BDCG, PDCG, ICG, and CG). The differences in the relative distribution among the groups were tested by Pearson's Chi-square test. Independent samples t-test was used to test the significance of differences between the two groups.
Results: In BDCG, retrognathic maxilla, tip up maxilla, retrognathic mandible, skeletal Class II, and horizontal growth pattern were the significant factors. In PDCG, skeletal Class II and hypodivergent were significant factors. In ICG, retrognathic maxilla, retrognathic mandible, hypodivergent relationships are poorly significant factors. The nasolabial angle and Steiner's S line were insignificant in all groups except the ICG where acute nasolabial angle is poorly significant.
Conclusion: When compared to controls, canine impaction(s) revealed a trend toward retrognathic maxilla, retrognathic mandible, skeletal Class II, and hypodivergent skeletal relationship.

Keywords: Buccally displaced canine group, impacted canine group, palatally displaced canine group


How to cite this article:
Singh S, Batham PR, Garg A, Virang B, Pereira Kalia UD. The effect of displaced canine on the dentoskeletal and soft tissue development of the face: A cephalometric study. Int J Orthod Rehabil 2018;9:14-22

How to cite this URL:
Singh S, Batham PR, Garg A, Virang B, Pereira Kalia UD. The effect of displaced canine on the dentoskeletal and soft tissue development of the face: A cephalometric study. Int J Orthod Rehabil [serial online] 2018 [cited 2018 Oct 21];9:14-22. Available from: http://www.orthodrehab.org/text.asp?2018/9/1/14/226243


  Introduction Top


The maxillary permanent canines act as the cornerstone of occlusion and play a key role in smile designing. Any morphological defect or eruption anomaly, affecting the maxillary permanent canine, has a negative impact on the smile and facial esthetics of the individual.[1],[2],[3] Impaction is defined as a cessation of eruption of a tooth caused by a physical barrier in the eruption path or “the abnormal position of the tooth.”[4] The tooth impaction is the infraosseous position of the tooth after the expected time of eruption, whereas the anomalous infraosseous position of the canine before the expected time of eruption is defined as a displacement.[5] Maxillary canines are among the last teeth to develop and have the longest period of development. They also have the longest and most devious path of eruption from the formation point lateral of the pisiform fossa to the final position in the dental arch.[6] Permanent maxillary canines are the second most frequently impacted teeth; the prevalence of their impaction is 1%–2% in the general population. This makes the maxillary canine the second most commonly impacted tooth, after third molars.[7],[8],[9] Nearly 85% of impacted maxillary permanent cuspids are palatal impactions, and 15% are labial impactions.[10],[11],[12] The prevalence of impaction appears to be higher in females compared to males, with the reported ratio ranging from 1.3:1 to 3.2:1.[13] Palatally erupting or impacted maxillary canines occur twice as often in females than males, have a high family association, and are 5 times more common in Caucasians than Asians. It is not unusual for maxillary canine impaction to occur bilaterally, although unilateral ectopic eruptions are more frequent.[14] Individuals with canine impactions demonstrated profound maxillary deficiency located in anterior portion of the dental arch. No significant difference in arch form was noted.[15] Studies showed that palatally displaced canines show prognathic maxilla, a significant skeletal Class I facial profile with retroclination of maxillary central incisors and hypodivergent relationship whereas buccally displaced canine shows retrognathic maxilla, skeletal Class III facial profile with retroclination of maxillary incisors.[16] The palatally displaced canines occurred mostly in Class I skeletal and Class II division 2 incisor relationships with reduced vertical dimensions, short maxilla and mandibular body, small dentoalveolar heights, and reduced upper and lower lips.[17] There are many literatures available on diagnosis, prevalence, frequency, etiology, and associated developmental anomalies and maxillary transverse discrepancy of canine impaction. There are limited literatures found on dentoskeletal morphology of hard and soft tissue development of face of buccally displaced canine group (BDCG), palatally displaced canine group (PDCG), and impacted canine group (ICG) together. Besides there are limited studies available for this orthodontically important anomaly, the results are likely to yield clinically useful information about the risk factors, early diagnosis, and eventual treatment planning of maxillary permanent displaced canines.

The purpose of this study is to evaluate the effect of displaced canine on the dentoskeletal and soft tissue development of face of BDCG, PDCG, and ICG using cephalometric parameters.


  Materials and Methods Top


A cross-sectional clinical study was designed and conducted obtaining the approval of the Institutional Ethics Committee at the Department of Orthodontics and Dentofacial Orthopedics. Patients of 14–28 years' age group were examined clinically for displaced permanent canine, i.e., buccally and palatally impacted. For patients who have buccally and palatally displaced permanent canines, a lateral cephalogram was taken, and for clinically missing permanent canine cases, an orthopantomograph was taken to determine the type of impaction, i.e., unilateral and bilateral impaction or for missing teeth. Patients with a history of trauma or extraction of any primary or permanent teeth, orofacial clefts or any hereditary, and syndromic or systemic manifestations were excluded from the study.

The lateral cephalograms of each of the 50 controls and 75 displaced canine cases were hand traced with a 0.3 mm pencil on a ultrathin 0.003″ transparent matte acetate transparent sheet. 75 All the cephalometric radiographs were evaluated on a masked, illuminated viewbox in a room with reduced lighting and were measured manually. The cephalometric measurements were performed by the same investigator [Graph 1] and [Graph 2].



The cephalometric parameters evaluated to estimate the craniofacial skeletal relationship were as follows: sagittal parameters: sella-nasion-A point angle (SNA), sella-nasion-B point angle (SNB), A point-nasion-B point angle (ANB), upper incisor-sella-nasion (UI/SN); whereas vertical parameters: sella-nasion, gonion-gnathion plane angle (SN^GoGn); sella-nasion-anterior nasal spine-posterior nasal spine plane angle (SN^ANS-PNS); anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle (ANS-PNS^GoGn) and posterior facial height (sella-gonion), anterior facial height (nasion-menton) ratio (PFH/AFH) of Jaraback, to evaluate the craniofacial skeletal divergence.

Cephalometric parameters evaluated to estimate the craniofacial soft tissue relationship were Nasolabial angle (Cm-Sn-Ls degree) and S line of Steiner (line extending from the soft tissue contour of the chin to the middle of S formed by the lower border of the nose) used to evaluate craniofacial soft tissue divergence [Table 1].
Table 1: The cephalometric parameters evaluated to estimate the craniofacial skeletal relationship

Click here to view


Statistical analysis

Results on continuous measurements presented on mean ± standard deviation with 95%. The intra- and inter-group comparisons were used to identify the significance of differences in various selected cephalometric measurements. Assuming the normality of the distributions, one-way analysis of variance (ANOVA) was used to identify the differences in angles among the four groups (BDCG, PDCG, ICG, and CG). All selected angles were divided into respective diagnostic subcategories. The differences in the relative distribution of the various diagnostic subcategories among the four groups were tested by Pearson's Chi-square test. Independent samples t-test was used to test the significance of differences between the two groups, such as BDCG and CG, PDCG and CG, and ICG and CG, for all selected cephalometric measurements. Ninety-five percent confidence limits of normal Class I lateral cephalograms were calculated to identify the range (minimum–maximum) among normal controls. P > 0.05 was considered statistically insignificant, but the value from P < 0.06 to P < 0.09 was considered suggestively or poorly significant. The value from P < 0.05 to P < 0.02 was considered statistically significant whereas from P < 0.01 to P < 0.0001 was considered statistically highly/strongly significant.


  Results Top


[Table 2] shows the distribution of dentoskeletal features and statistical determination of differences in observed proportions of various diagnostic subcategories of angles: SNA, SNB, ANB, ML-SN, and UI-SN among four groups. The statistical agreement projected that cephalometric measurement differences of angles such as SNA, SNB, ANB, and ML/SN among patients were the significant factors of cephalometric features that displaced groups [Graph 3] and [Graph 4].
Table 2: Distribution of dentoskeletal features and statistical determination of differences in observed proportions of various diagnostic subcategories of angles: Sella-nasion-A point angle, sella-nasion-B point angle, A point-nasion-B point angle, mandibular line-sella-nasion and upper incisor-sella-nasion among four groups

Click here to view



[Table 3] shows distribution of dentoskeletal features and statistical determination of differences in observed proportions of various diagnostic subcategories of angles: SN^ANS-PNS, ANS-PNS^GOGN, ratio (PFH/AFH), and CM-SN-LS among all four groups. The statistically cephalometric measurement differences of angles such as ANS-PNS^GoGn, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Is among patients were the significant factors of cephalometric features that displaced groups.
Table 3: Distribution of dentoskeletal features and statistical determination of differences in observed proportions of various diagnostic subcategories of angles: Sella-nasion-anterior nasal spine-posterior nasal spine plane angle, anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle, ratio (posterior facial height [sella-gonion], anterior facial height [nasion-menton] ratio) and CM-SN-LS among all four groups

Click here to view


[Table 4] shows comparison of various diagnostic subcategories of angles: SNA, SNB, ANB, ML/SN, and UI/SN between BDCG and control group (CG). The SNA, SNB, ANB, and ML/SN were the significant factors among patients of BDCG.
Table 4: Comparison in various diagnostic subcategories of angles: Sella-nasion-A point angle, sella-nasion-B point angle, A point-nasion-B point angle, mandibular line/sella-nasion and upper incisor/sella-nasion between buccally displaced canine group and control group

Click here to view


[Table 5] shows comparison of various diagnostic subcategories of angles: SN^ANS-PNS, ANS-PNS^GOGN, ratio (PFH/AFH), and Cm-Sn-Ls between BDCG and CG. The SN^ANS-PNS and ratio (PFH/AFH) of Jaraback were the significant factors that observed carefully while treating patients of BDCG orthodontically.
Table 5: Comparison in various diagnostic subcategories of angles: Sella-nasion-anterior nasal spine-posterior nasal spine plane angle, anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle, ratio (posterior facial height [sella-gonion], anterior facial height [nasion-menton]) and CM-SN-LS between buccally displaced canine group and control group

Click here to view


[Table 6] shows comparison of various diagnostic subcategories of angles: SNA, SNB, ANB, ML/SN, and UI/SN between PDCG and CG. The SN^ANS-PNS and ratio (PFH/AFH) of Jaraback were the significant factors that observed carefully while treating patients of BDCG orthodontically.
Table 6: Comparison in various diagnostic subcategories of angles: Sella-nasion-A point angle, sella-nasion-B point angle, A point-nasion-B point angle, mandibular line/sella-nasion and upper incisor/sella-nasion between palatally displaced canine group and control group

Click here to view


[Table 7] shows comparison of various diagnostic subcategories of angles: SN^ANS-PNS, ANS-PNS^GOGN, ratio (PFH/AFH), and Cm-Sn-Ls between PDCG and CG. The SN^ANS-PNS, ANS-PNS^GoGn, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Ls were not the significant factors among patients of PDCG.
Table 7: Comparison in various diagnostic subcategories of angles: Sella-nasion-anterior nasal spine-posterior nasal spine plane angle, anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle, ratio (posterior facial height [sella-gonion], anterior facial height [nasion-menton]) and CM-SN-LS between palatally displaced canine group and control group

Click here to view


[Table 8] shows comparison of various diagnostic subcategories of angles: SNA, SNB, ANB, ML/SN, and UI/SN between impacted displaced canine group and CG. The SNA, SNB, and ML/SN were the factors among patients of impacted displaced canines may observe carefully while treating patients orthodontically.
Table 8: Comparison in various diagnostic subcategories of angles: Sella-nasion-A point angle, sella-nasion-B point angle, A point-nasion-B point angle, mandibular line/sella-nasion and upper incisor/sella-nasion between impacted displaced canine group and control group

Click here to view


[Table 9] shows comparison of various diagnostic subcategories of angles: SN^ANS-PNS, ANS-PNS^GOGN, ratio (PFH/AFH), and Cm-Sn-Ls between impacted displaced canine group and CG. The SN^ANS-PNS, ANS PNS^GoGn, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Ls but were not the significant factors among patients of impacted canines.
Table 9: Comparison in various diagnostic subcategories of angles: Sella-nasion-anterior nasal spine-posterior nasal spine plane angle, anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle, ratio (posterior facial height [sella-gonion], anterior facial height [nasion-menton]) and CM-SN-LS between impacted displaced canine group and control group

Click here to view


[Table 10] shows comparison of angles: SNA, SNB, ANB, ML/SN, and UI/SN of permanent maxillary displaced canine(s) among studied groups. The statistical comparison among four groups (BDCG, PDCG, ICG, and CG) showed highly significant differences with respect to two measurements, namely SNA and SNB while significant differences for angle UI/SN angle but no statistical differences for angles ANB and ML/SN.
Table 10: Comparison in angles: Sella-nasion-A point angle, sella-nasion-B point angle, A point-nasion-B point angle, mandibular line/sella-nasion, and upper incisor/sella-nasion of permanent maxillary displaced canine(s) among studied groups

Click here to view


[Table 11] shows comparison of angles: SN^ANS-PNS, ANS-PNS^GOGN, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Ls for permanent maxillary displaced canine (s) among groups. The statistical comparison among all four groups showed no significant differences with respect to four measurements, namely SN^ANS-PNS, ANS-PNS^GoGn, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Ls angles among patients of all four groups.
Table 11: Comparison in angles sella-nasion-anterior nasal spine-posterior nasal spine plane angle, anterior nasal spine-posterior nasal spine plane-gonion-gnathion plane angle, ratio (posterior facial height [sella-gonion], anterior facial height [nasion-menton]) of Jaraback and CM-SN-LS for permanent maxillary displaced canine(s) among groups

Click here to view



  Discussion Top


There are many literatures available on diagnosis, prevalence, frequency, etiology, and associated developmental anomalies and maxillary transverse discrepancy of canine impaction. There are limited literatures found on dentoskeletal morphology of hard and soft tissue development of face of BDCG, PDCG, and ICG together. Besides this, there are limited studies available for this orthodontically important anomaly. Female is more common in BCDG and PDCG,[18] but in the present study, male is common in BDCG and female is common in PDCG and ICG. In the present study, prevalence rate BDCG 40% followed by ICG 40% and PDCG is 20%, Impacted maxillary permanent cuspids, i.e. palatal impaction is 85% and buccally/labially 15%.[8],[9],[10],[11],[18],[19] This study shows that BDCG is having retrognathic maxilla, retrognathic mandible and skeletal Class II, retrocliantion of incisor is statistically significant. However, other studies reported that no significant associations were found between BDC and the skeletal features, except for increased ANB angle.[20] BDC did not demonstrate significant associations with any specific craniofacial pattern in the sagittal plane (skeletal Class I, II, or III) when compared with the CG.[21] In the present study, BDCG show results of hypodivergent of ML/SN, horizontal grower in PFH/AFH is significant whereas tip up maxilla among the subject is highly significant, while study only reported that a significant association between BDC and vertical craniofacial features.[22]

The study showed that skeletal Class II is significant, retrognathic mandible is poorly significant and nonsufficient SNA in PDCG. The study was supported that statistically significant associations between PDC and SNB, ANB.[20] PDCG was found most frequently in patients with Class I skeletal relationship.[17],[23] This study showed that PDC was more frequent in Class II division 2 incisor relationships. In the present study, PDCG show hypodivergent relationship of ML/SN while the present research indicated that the diagnostic subcategory differences with respect to angles such as SN^ANS-PNS, ANS-PNS^GoGn, ratio (PFH/AFH) of Jaraback were not the significant factors among patients in PDCG. Statistically significant SN^GoGN, SN^ANS-PNS, ANS-PNS^GoGn, PFH/AFH, while no significant associations emerged between PDC and SNA, SNBa and the growth parameters of Jarabak.[20] Three times higher prevalence rate for hypodivergent cases in the PDC patients compared to the control cases.[23] Individuals with PDCs were found to have significantly increased interincisal angle (UI/LI) than controls. Although overbite was not statistically significantly different. PDCs were found more in Class II division 2 incisors in which interincisal angle usually tends to be increased.[24]

The study shows that ICG has poorly significant orthognathic mandible and SNA and nonsignificant ANB. PMC impaction cases to be associated with the retrognathic mandible, skeletal Class II, retroclined mandibular when compared to CG.[25],[26] The diagnostic subcategory differences with respect to angles such as SN^ANS-PNS, ANS-PNS^GoGn, and ratio (PFH/AFH) of Jaraback were not the significant factors among impacted canines' patients while UI/SN study supported that retroclined mandibular and maxillary incisors occurred significantly most frequently and proclined mandibular incisors significantly least frequently in “IG.” There is a significant association of mandibular canine impaction with retroclined maxillary incisors too. As Class II division 2 malocclusion (Class II/2) is typically associated with retroclined incisors.[27],[28]

In the present study, results showed that there is no statistically significant association with BDCG, PDCG, and ICG in soft tissue parameters, and other studies showed that upper and lower lips were significantly retruded relative to the Ricketts E-plane [Table 12]. These soft tissue findings may be explained by the presence of short maxilla and mandible where upper and lower lips will follow the underlying hard tissues.[17]
Table 12: Distribution of Steiner's S-line with respect to maxilla and statistical determination of differences in observed proportions of various diagnostic subcategories among four groups

Click here to view


In the study assuming the normality of the distributions, one-way ANOVA was used to identify the differences in angles among the four groups (BDCG, PDCG, ICG, and CG) and the result showed that SNA and ANB and ANSPNS-GoGN, PFH/AFH is highly significant, whereas SNB and ML/SN and Nasolabial angle is significant. However, according to ANOVA test, PDC patients have more significant SNA and significant 1/SN, ML/SN, and Spl/ML angles compared to control.[16] There are no significant differences with respect to four measurements, namely SN^ANS-PNS, ANS-PNS^GoGn, ratio (PFH/AFH) of Jaraback, and Cm-Sn-Ls angles among patients of all four groups.


  Conclusion Top


Based on the results of the present study, it can be concluded that as follows:

  • There is a significant association with retrognathic maxilla, retrognathic mandible, and skeletal Class II in BDCG
  • BDCG also shows significant hypodivergent skeletal relationship with tip up maxilla and retroclination of incisors
  • Whereas skeletal Class II and hypodivergent skeletal relationship are significant while retrognathic mandible is poorly significant in PDCG
  • There is positive association retroclination of incisors are while retognathic maxilla, retrognathic mandible, hypo divergent relationship is poorly significant association in ICG
  • Nasolabial angle and Steiner's Soft tissue are insignificant in BDCG, PDCG, and ICG
  • Female is more common in BDCG and PDCG whereas male is more common in ICG
  • Bilateral displacement is commonly seen in BDCG and PDCG, whereas unilateral displacement is commonly seen in ICG.


There are no conflicts of interest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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