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Dentomaxillofacial Radiology (2013) 42, 20130129

2013 The Authors. Published by the British Institute of Radiology


http://dmfr.birjournals.org

RESEARCH
Comparison of methods for localization of impacted maxillary
canines by panoramic radiographs
S An, J Wang*, J Li, Q Cheng, C-M Jiang, Y-T Wang, Y-F Huang, W-J Yu, Y-C Gou and L Xiao

Department of Orthodontics, West China Hospital of Stomatology, West China College of Stomatology, Sichuan University,
Chengdu, China

Objectives: The objective of this study was to compare three methods for localization of
impacted maxillary canines using only conventional panoramic radiographs.
Methods: The panoramic radiographs of 94 patients (102 impacted maxillary canines) were
reviewed and evaluated using the methods magnification, angulation and superimposition.
The actual positions of them were decided with cone beam CT images. The predicted
positions of impacted canines from the magnification and angulation methods were compared
using the McNemar x 2 test. Sensitivity, specificity, accuracy, positive-likelihood ratio and
negative-likelihood ratio were calculated. The canine-incisor index values and a angles of
palatally and bucally non-rotated impacted canines were compared using the MannWhitney
U test.
Results: The statistical analysis revealed that there was a significant difference between the
magnification and angulation methods (p , 0.01). Using the magnification method, 68.00%
of buccal canines and 69.57% of palatal canines could be localized correctly. The results of the
angulation method were 28.57% and 84.91%, respectively. The sensitivity of the angulation
method for buccal canines was very low. In the superimposition method, 82.98% of the
superimposing samples were palatal.
Conclusions: The magnification and angulation methods were not reliable methods for
locating the impacted canine with a single panoramic radiograph. Magnification was more
successful than the angulation method. Further research is needed on the magnification
method. The image superimposition method could be used as an adjunct to others.
Dentomaxillofacial Radiology (2013) 42, 20130129. doi: 10.1259/dmfr.20130129

Cite this article as: An S, Wang J, Li J, Cheng Q, Jiang C-M, Wang Y-T, et al. Comparison of
methods for localization of impacted maxillary canines by panoramic radiographs.
Dentomaxillofac Radiol 2013; 42: 20130129.

Keywords: localization; impacted canine; panoramic radiograph; magnification; angulation

Introduction

Impactions permanent maxillary canines are the have reported that 85% of impacted maxillary canines
second-most frequently impacted teeth following the localized palatally, whereas 15% localized buccally.57
third molars, and the prevalence of their impaction However, the ratio is different in diverse populations.810
varies from less than 1% to 3%.13 In China, the in- For Chinese orthodontic patients, the ratio of palatal
cidence of permanently impacted teeth, except the third displacement to buccal is 1:2.1.11 This could be ascribed
molars, was reported as 6.15%, with impacted canines to genetic factors.
being the most prevalent (28.10%).4 Many researchers Localization of impacted maxillary canines influences
treatment planning and prognosis evaluation. Traditional
*Correspondence to: Dr Jun Wang, Department of Orthodontics, West China
radiographic analysis techniques include parallax and
College of Stomatology, Sichuan University, 14#, 3rd section, Renmin South
Road, Chengdu 610041, China. E-mail: wangjunv@scu.edu.cn magnification. Parallax was introduced by Clark12 with
Received 8 April 2013; revised 17 July 2013; accepted 24 July 2013 the following principle: owing to parallax, when the tube
Radiographic localization of impacted canine
2 of 6 S An et al

moves, the images of more distant (lingual) objects


move in the same direction as the tube shift, whereas the
images of closer (buccal) objects move in the opposite
direction. This is called the same lingual opposite buccal
rule. This method requires two periapical radiographs
made at different angles or a panoramic radiograph and
an anterior maxillary occlusal radiograph. However,
the magnification method requires a panoramic image.
Panoramic radiography as a narrow beam rotation
radiography method produces a layer of defined
thickness; when the object is positioned outside the
centre of this sharp layer, magnification and distortion
effect occurs in the image. Welander and Wickman13
and Welander14 have analysed mathematically the layer
formation and image distortion in narrow beam radiog- Figure 1 Vertical zones in magnification method. The root length of
raphy. Devlin and Yuan15 have demonstrated that object the ipsilateral central incisor was divided into three equal zones and
position can be derived from measured image magnifi- impacted canines were classified as apical zone, middle zone or
coronal zone, according to their crown position
cation. The projective magnification in panoramic radi-
ography is related to the distance between the object and
the tube: the object placed farther to the tube (buccal) that were superimposed on the root or neck of the central
throws a smaller shadow on the film than the one placed incisor were located palatally. Smailiene21 found that
closer. canines that overlapped with the longitudinal axis of the
A CT scan can provide a three-dimensional image in lateral incisors were positioned palatally.
which the position of the impacted canine and the re- Katsnelson et al22 introduced a new simple method to
lationship with adjacent structures, such as incisors, are use a panoramic radiograph to evaluate the position of
more easily appreciated. CT scans are not without dis- impacted maxillary canines. The angulation of the canine
advantages. Firstly, there is an increase in the radiation to the occlusion plane was measured using a panoramic
dose and cost to the patients. Secondly, not every dental radiograph; if the angulation was greater than 65, it
clinic has the facilities to provide CT examination. was 26.6 times more likely to reflect a buccally im-
In comparison, panoramic radiographs are common for pacted than a palatally impacted maxillary canine. Their
orthodontic patients and provide useful clinical infor- explanation was that the palatally located tooth could
mation at a lower radiation dose and financial cost. It not have been positioned vertically because the palatal
would be desirable if orthodontists could find a reliable bone is thin in the sagittal dimension.
method to determine the possible position of impacted Based on the above description, magnification,
canines simply by viewing a panoramic radiograph. Some angulation and superimposition are simple practical
scholars have explored this hypothesis in accordance with methods of localizing impacted canine using a single
the principle of magnification, such as Wolf and Mattila,16 panoramic radiograph. This study is designed to re-
Fox et al17 and Chaushu et al.18 Compared with the evaluate the three methods and to compare them with
previous related researches, Chaushu et al18 took into each other, and then ascertain whether there is a reli-
consideration the influence that the distance from the able method for localizing impacted canines by
radiation source has on the vertical location of the ob- viewing a panoramic radiograph.
ject on the panoramic radiograph. They suggested com-
bining the vertical restriction (apical, middle or coronal)
and the canine-incisor index (CII) to determine the position Materials and methods
of an unerupted maxillary canine. In their research, im-
pacted canines were classified as apical, middle or coronal This study was designed according to the principles of
according to the vertical position of crown relative to the the Helsinki Declaration; ethical approval was obtained
adjacent erupted incisor (Figure 1). The CII was defined from the West China Hospital of Stomatology Institute
as the ratio of the crown width of the impacted canine to Review Board (Chengdu, China). The approval number
the crown width of the ipsilateral central incisor crown. is 2011010. Patients with at least one impacted per-
The results showed that when an unerupted canine is manent maxillary canine who were treated in the
middle or coronal, consistently accurate diagnoses could Department of Orthodontics in West China College of
be made, and the cut-off point of CII is 1.15; this was Stomatology were reviewed in this study. The inclusion
in agreement with previous studies. Another study criteria for the subjects included: (1) clear digital pano-
arrived at similar conclusions.19 Mason et al20 evalu- ramic radiograph was present; (2) a cone beam CT (CBCT)
ated two localization methods and reported that 76% image was present; (3) all permanent teeth had erupted
of the impacted canines could be correctly located with except the impacted canines and/or the third molars. The
vertical parallax and 66% with magnification. Wolf exclusion criteria included craniofacial syndromes or
and Mattila16 proposed that impacted maxillary canines cleft palate.

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The CBCT examination was acquired when the im-


pacted canine could not be located exactly by panoramic
radiography and clinical assessment such as palpation.
Therefore, both panoramic radiographs and CBCT
images were present for the patients group. Finally, 94
subjects (102 impacted canines) were enrolled in the
study, including 42 males and 52 females, with ages
ranging from 10 years to 29 years. All panoramic radio-
graphs were numbered and the following measurements
were performed in each panoramic radiograph:
Figure 3 Experimental design. The localizing methods were decided
1. The widest mesiodistal crown dimension of each im- based on the vertical categorization of each impacted canine
pacted canine and ipsilateral central incisor was mea-
sured, and the CII values were calculated. Three methods were used to localize impacted canines:
2. The height of the cusp of each impacted canine was magnification, angulation and superimposition. Canines
assessed in the vertical plane relative to the ipsilateral that were rotated or located in the apical zone were ex-
central incisor. The length of the axis of the ipsilateral cluded from the magnification method. The experimental
central incisor was measured and divided into three design is showed in Figure 3.
equal zonesapical, middle and coronal. Then the
1. Magnification: based on the research by Chaushu
vertical position of the tip of crown of the impacted
et al18 and Sudhakar et al,19 in which the vertical
canine by the zones was evaluated (Figure 1).
restriction of the impacted canine was considered
3. The angulation of the long axis of the impacted
as an element of localization, CII 5 1.15 was selected
canine to the occlusion plane was measured (a angle,
to be the cut-off point. When the value of CII was
Figure 2). The occlusion plane was obtained by
greater than or equal to 1.15, it indicated palatal
connecting the mesiobuccal cusp tips of the two
location; less than 1.15 indicated buccal location.
maxillary first molars.
Canines that were rotated or located in the apical
4. Whether the impacted canine was superimposed on
zone were excluded. Finally, 48 canines were eligible
the root or neck of the central incisor was evaluated.
for the magnification method.
2. Angulation: based on the research by Katsnelson
The examiner was blinded to the canine position and et al,22 which demonstrated that the angulation of 65
patient information. All the above measurements were was the best combination of sensitivity and specificity
repeated after 2 weeks by the same examiner, and the to distinguish between the buccally and palatally
average values were finally adopted. Another researcher impacted canines, a 5 65 was considered as the cut-
collected the actual positions of impacted canines from off point. When the value of a was less than or equal
their corresponding CBCT images. The treatment to 65, it indicated palatal location; greater than 65
approaches of the canines impacted buccally and in the indicated buccal location. Firstly, the angulation
line of the arch are similar, so they were collectively re- method was used to evaluate the canines that were
ferred to as buccal canine in this study. enrolled in the magnification method and then to
evaluate all the canines of the study.
3. Superimposition: this method is only fit for the
superimposed canines. The impacted maxillary
canine that was superimposed on the root or neck
of the central incisor was considered as a palatally
impacted canine.

Statistical analysis
Comparison of magnification and angulation methods:
the predicted positions of impacted canines from the two
methods were compared using the McNemar x2 test.
p , 0.05 was considered statistically significant.
The predicted positions from the magnification and
angulation methods were then compared with the actual
positions collected from CBCT images. Sensitivity, speci-
ficity, accuracy, positive-likelihood ratio and negative-
likelihood ratio were calculated.
Figure 2 Measurement of a angle in the angulation method. The
occlusion plane was obtained by connecting mesiobuccal cusp tips of The CII values and a angles of palatally and bucally
the two maxillary first molars, and the a angle was the angulation of non-rotated impacted canines were compared using
the long axis of the impacted canine to the occlusion plane the MannWhitney U test. Statistical analysis was

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Table 1 Distribution of the impacted canines positions and the ranges of CII values and a angles for different zones

Vertical position Buccal Palatal


of the canines n Range of CII values Range of a angles n Range of CII values Range of a angles Total
Apical 18 0.871.37 10.587.0 21 1.101.41 569
Middle 22 1.031.32 12.074.5 17 1.091.39 13.584.5
Coronal 9 0.851.19 49.089.5 15 1.051.40 1989
Total 49 0.851.37 10.589.5 53 1.051.41 589 102
CII, canine-incisor index.

performed using SPSS for Windows (v. 10.0; SPSS Inc., 32 (59.26%) canines could be correctly localized using the
Chicago, IL). superimposition method. This was especially true of
the 30 rotated canines; 23 (76.67%) of them were partly
Results superimposed on the central incisor.

The panoramic radiographs of 94 subjects were en- Discussion


rolled in the study and 8 showed bilateral impactions.
102 maxillary impacted canines were included in the In this study, three methods were used for determining
study. Based on the CBCT images, 49 (48.04%) were the position of impacted maxillary canines using a pan-
located buccally and 53 (51.96%) palatally. Table 1 oramic radiograph (Figure 3). The mechanism of image
shows the distribution of the impacted canines positions formation in panoramic radiography is that the tube
and the ranges of CII values and a angles for different emits radiation that is limited to a narrow vertical beam,
zones. It can be seen that for every zone, there are and the film moves in the contrary direction to the tube,
overlaps in the ranges. A significant difference was which allows exposure of only a small part of the film
found between the magnification and angulation meth- through a narrow slit. The narrow vertical beam is used,
ods (x 2 5 6.66, p , 0.01, Table 2). Table 3 is a fourfold rather than the larger circular or rectangular beam used
table of the magnification and angulation methods in conventional intraoral radiography. In the magnifi-
compared with CBCT. Sensitivity here stood for the cation method, the vertical restriction of the impacted
probability that a buccal canine could be localized cor- canines should be assessed because the X-ray beam is
rectly, whereas specificity was for a palatal one. When directed from a slight negative angulation (24 to 27),
using the magnification method, the sensitivity and and accordingly the object placed near to the film
specificity both approximated to 70% (Tables 3 and 4). (palatal) will be projected to a more superior level on
However, many buccal canines were diagnosed as being the film.18 In addition, different magnification factors
palatal when using the angulation method (Tables 3 and 4). are valid for the horizontal and vertical dimensions in
Application of the MannWhitney U test to compare the image.13,14 The vertical and horizontal magnifica-
the CII values and a angles of non-rotated palatally and tion are related to projective magnification; the horizontal
buccally impacted canines showed no statistically signif- magnification is also dependent on the magnification
icant differences (p . 0.05). Analysis based on different induced by the speed the beam traverses the object.
zones revealed that in the coronal zone, there was a Devlin and Yuan15 have demonstrated that there is
statistically significant difference between non-rotated
palatally and buccally impacted canines in relation to
CII (p 5 0.001) and a (p 5 0.018). Table 3 Fourfold tables of magnification and angulation methods
Using the superimposition method (Table 5), 82.98% compared with CBCT
of the superimposing samples were palatal. In the CBCT
remaining eight buccal canines, six had obvious central Localization method Localization result Buccal Palatal Total
incisor resorption. Magnification Buccal 17 7 24
The canines that were excluded from the magnification Palatal 8 16 24
method because of rotation or being located in the apical
Total 25 23 48
zone were also analysed (54 canines). It was found that Angulation 1 Buccal 9 4 13
Palatal 16 19 35
Table 2 Fourfold table of comparison between magnification and
angulation methods Total 25 23 48
Magnification Angulation 2 Buccal 14 8 22
Palatal 35 45 80
Angulation Buccal Palatal Total
Buccal 11 2 13 Total 49 53 102
Palatal 13 22 35 CBCT, cone beam CT.
Angulation 1: the canines that were enrolled in magnification were
Total 24 24 48
re-evaluated by the angulation method.
*x 2 5 6.66 (*Significant difference between magnification and angu- Angulation 2: all the canines of the study were evaluated by the
lation; p , 0.01). angulation method.

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Table 4 Values of sensitivity, specificity, accuracy, positive-likelihood ratio and negative-likelihood ratio
Localization method Sensitivity (%) Specificity (%) Accuracy (%) Positive-likelihood ratio Negative-likelihood ratio
Magnification 68.00 69.57 68.75 2.23 0.3757
Angulation 1 34.61 82.61 58.33 2.07 0.7747
Angulation 2 28.57 84.91 57.84 1.89 0.8412

more variation in the horizontal direction than in the using the magnification method, 68.00% of buccal canines
vertical direction of an image when an object is placed in and 69.57% of palatal canines could be localized correctly.
random positions about the sharp layer. In this study, the The difference in sensitivity between buccal and palatal
magnification method (combined vertical restriction and canines was not obvious. The results implied that the
CII) did not confirm the conclusion of Chaushu et al.18 magnification method could be used for the population
The diagnostic accuracy rate was approximately 70% and with higher incidences of buccally impacted canines.
it was quite different from the 100% in Chaushus study, Wolf and Mattila16 observed 47 impacted maxillary
which did not exclude the rotated canines. The widest canines projected on the root or neck of the central
mesiodistal crown dimension of rotated impacted canine incisor and found they were all located palatally.
was not reliable by measurement from a panoramic By coincidence, in our study, we also observed 47 super-
radiograph, so the CII value could not be calculated. imposing canines, of which 39 were located palatally and
The results showed that in the magnification method 8 were located buccally. Besides, obvious resorption of
(combined vertical restriction and CII), 68.00% of buccal the center incisor could be observed in these buccally
canines and 69.57% of palatal canines could be localized located canines. Recently, Jung at el24 reported that
correctly. Canines that were rotated or located in the mid-alveolus impacted canines in CBCT were more
apical zone were excluded from the magnification frequent in panoramic Sector 4 (the area from the
method, and only 48 canines were eligible for this method. distal aspect to the midline of the central incisor) and
However, in this study, the results of the MannWhitney palatally impacted canines were more frequent in
U test revealed that in the coronal zone, there was a sta- panoramic Sector 5 (the area from the midline of the
tistically significant difference between palatally and buc- central incisor to the midline of the maxillary arch).
cally impacted canines in relation to CII. It suggested that This implied that not every impacted canine projected
further research with an expanded sample size is needed. on the root or neck of the central incisor was located
The angulation of the long axis of the impacted ca- palatally, which was in accordance with our finding.
nine to the occlusion plane (angulation method) was Therefore, the superimposition method can be used only
also not suitable for localization of impacted canines us- as an adjunct to the other methods. In particular, this
ing panoramic radiographs. study showed that most of the canines that were excluded
However, some findings in our study were different from the magnification method because of rotation or
from those in previous reports. Many researchers have being located in the apical zone were superimposed on the
reported that 85% of impacted maxillary canines root or neck of the central incisors.
were localized palatally, whereas 15% were localized
buccally. 57 However, buccally located canines are more Conclusion
common among Chinese patients. Wolf and Mattila16
pointed out that the magnification method was much Magnification and angulation methods were not reliable
more accurate in detecting palatally impacted canines methods for locating the impacted canines with a single
than buccal ones because the magnification was larger panoramic radiograph. The magnification method was
for palatally located canines. In the study by Mason more successful than the angulation method. Further
et al,20 90% of palatal canines and only 10% of buccal research is needed for the magnification method, while
canines could be detected with magnification. The study the image superimposition method could be used as an
by Nagpal et al23 was in accordance with this report. It adjunct to other methods of localization.
seems that the magnification method has some obvious
limitations for Chinese patients. However, in this study,
Acknowledgments
Table 5 Buccalpalatal positions of the impacted maxillary canines
that were superimposed on the root or neck of the central incisor and
The authors are grateful to the X-ray department of
root resorption situation of the central incisors West China College of Stomatology. We would also like
to thank all the orthodontists and their patients who
Superimposing Buccal Central incisor root resorptiona 6 participated in this study.
No central incisor root resorption 2
Palatal Central incisor root resorption 5
No central incisor root resorption 34
Funding
a
Central incisor root resorption here defined as the obvious
resorption of the central incisor, which could be detected from the This study was supported by the Sichuan Provincial
panoramic radiograph. Foundation (Grant no: 2009SZ0159).

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References

1. Grover PS, Lorton L. The incidence of unerupted permanent teeth 13. Welander U, Wickman G. Image distortion in narrow beam rotation
and related clinical cases. Oral Surg Oral Med Oral Pathol 1985; radiography. A mathematical analysis. Acta Radiol Diagn (Stockh)
59: 420425. 1978; 19: 507512.
2. Dachi SF, Howell FV. A survey of 3,874 routine full-mouth 14. Welander U. Layer formation in narrow beam rotation radiography.
radiographs. II. A study of impacted teeth. Oral Surg Oral Med Acta Radiol Diagn (Stockh) 1975; 16: 529540.
Oral Pathol 1961; 14: 11651169. 15. Devlin H, Yuan J. Object position and image magnification in dental
3. Kramer RM, Williams AC. The incidence of impacted teeth. A panoramic radiography: a theoretical analysis. Dentomaxillofac
survey at Harlem hospital. Oral Surg Oral Med Oral Pathol 1970; Radiol 2013; 42: 29951683. doi: 10.1259/dmfr/29951683
29: 237241. 16. Wolf JE, Mattila K. Localization of impacted maxillary canines
4. Hou R, Kong L, Ao J, Liu G, Zhou H, Qin R, Hu K. by panoramic tomography. Dentomaxillofac Radiol 1979; 8: 8591.
Investigation of impacted permanent teeth except the third 17. Fox NA, Fletcher GA, Horner K. Localising maxillary canines
molar in Chinese patients through an X-ray study. J Oral Maxillofac using dental panoramic tomography. Br Dent J 1995; 179: 416420.
Surg 2010; 68: 762767. doi: 10.1016/j.joms.2009.04.137 18. Chaushu S, Chaushu G, Becker A. Reliability of a method for the
5. Rayne J. The unerupted maxillary canine. Dent Pract Dent Rec localization of displaced maxillary canines using a single pano-
1969; 19: 194204. ramic radiograph. Clin Orthod Res 1999; 2: 194199.
6. Abron A, Mendro RL, Kaplan S. Impacted permanent maxillary 19. Sudhakar S, Patil K, Mahima VG. Localization of impacted
canines. N Y State Dent J 2004; 70: 2428. permanent maxillary canine using single panoramic radiograph.
7. Warford JH Jr, Grandhi RK, Tira DE. Prediction of maxillary Indian J Dent Res 2009; 20: 340345. doi: 10.4103/0970-9290.57381
canine impaction using sectors and angular measurement. Am J 20. Mason C, Papadakou P, Roberts GJ. The radiographic localization
Orthod Dentofacial Orthop 2003; 124: 651655. doi: 10.1016/ of impacted maxillary canines: a comparison of methods. Eur J
S0889540603006218 Orthod 2001; 23: 2534.
8. Thilander B, Jakobsson SO. Local factors in impaction of maxillary 21. Smailiene D. Localization of impacted maxillary canines by palpation
canines. Acta Odontol Scand 1968; 26: 145168. and orthopantomography. Medicina (Kaunas) 2002; 38: 825829.
9. Bass TB. Observations on the misplaced upper canine tooth. Dent 22. Katsnelson A, Flick WG, Susarla S, Tartakovsky JV, Miloro M.
Pract Dent Rec 1967; 18: 2533. Use of panoramic x-ray to determine position of impacted maxillary
10. Fournier A, Turcotte JY, Bernard C. Orthodontic considerations canines. J Oral Maxillofac Surg 2010; 68: 9961000. doi: 10.1016/j.
in the treatment of maxillary impacted canines. Am J Orthod joms.2009.09.022
1982; 81: 236239. 23. Nagpal A, Pai KM, Setty S, Sharma G. Localization of impacted
11. Zhong YL, Zeng XL, Jia QL, Zhang WL, Chen L. Clinical in- maxillary canines using panoramic radiography. J Oral Sci 2009;
vestigation of impacted maxillary canine. Zhonghua Kou Qiang Yi 51: 3745.
Xue Za Zhi 2006; 41: 483485. 24. Jung YH, Liang H, Benson BW, Flint DJ, Cho BH, The assessment
12. Clark CA. A method of ascertaining the position of unerupted of impacted maxillary canine position with panoramic radiography
teeth by means of film radiographs. Proc R Soc Med 1910; 3: and cone beam CT. Dentomaxillofac Radiol 2012; 41: 356360.
8790. doi: 10.1259/dmfr/14055036

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