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
second-most frequently impacted teeth following the
third molars, and the prevalence of their impaction
varies from less than 1% to 3%.13 In China, the in-
cidence of permanently impacted teeth, except the third
molars, was reported as 6.15%, with impacted canines
being the most prevalent (28.10%).4 Many researchers
*Correspondence to: Dr Jun Wang, Department of Orthodontics, West China
College of Stomatology, Sichuan University, 14#, 3rd section, Renmin South
Road, Chengdu 610041, China. E-mail: wangjunv@scu.edu.cn
Received 8 April 2013; revised 17 July 2013; accepted 24 July 2013
have reported that 85% of impacted maxillary canines
localized palatally, whereas 15% localized buccally.57
However, the ratio is different in diverse populations.810
For Chinese orthodontic patients, the ratio of palatal
displacement to buccal is 1:2.1.11 This could be ascribed
to genetic factors.
Localization of impacted maxillary canines influences
treatment planning and prognosis evaluation. Traditional
radiographic analysis techniques include parallax and
magnification. Parallax was introduced by Clark12 with
the following principle: owing to parallax, when the tube
 Radiographic localization of impacted canine
2 of 6
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-
raphy. Devlin and Yuan15 have demonstrated that object
position can be derived from measured image magnifi-
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)
throws a smaller shadow on the film than the one placed
closer.
A CT scan can provide a three-dimensional image in
which the position of the impacted canine and the re-
lationship with adjacent structures, such as incisors, are
more easily appreciated. CT scans are not without dis-
advantages. Firstly, there is an increase in the radiation
dose and cost to the patients. Secondly, not every dental
clinic has the facilities to provide CT examination.
In comparison, panoramic radiographs are common for
orthodontic patients and provide useful clinical infor-
mation at a lower radiation dose and financial cost. It
would be desirable if orthodontists could find a reliable
method to determine the possible position of impacted
canines simply by viewing a panoramic radiograph. Some
scholars have explored this hypothesis in accordance with
the principle of magnification, such as Wolf and Mattila,16
Fox et al17 and Chaushu et al.18 Compared with the
previous related researches, Chaushu et al18 took into
consideration the influence that the distance from the
radiation source has on the vertical location of the ob-
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
of an unerupted maxillary canine. In their research, im-
pacted canines were classified as apical, middle or coronal
according to the vertical position of crown relative to the
adjacent erupted incisor (Figure 1). The CII was defined
as the ratio of the crown width of the impacted canine to
the crown width of the ipsilateral central incisor crown.
The results showed that when an unerupted canine is
middle or coronal, consistently accurate diagnoses could
be made, and the cut-off point of CII is 1.15; this was
in agreement with previous studies. Another study
arrived at similar conclusions.19 Mason et al20 evalu-
ated two localization methods and reported that 76%
of the impacted canines could be correctly located with
vertical parallax and 66% with magnification. Wolf
and Mattila16 proposed that impacted maxillary canines
Dentomaxillofac Radiol, 42, 20130129
S An et al
Figure 1 Vertical zones in magnification method. The root length of
the ipsilateral central incisor was divided into three equal zones and
impacted canines were classified as apical zone, middle zone or
coronal zone, according to their crown position
that were superimposed on the root or neck of the central
incisor were located palatally. Smailiene21 found that
canines that overlapped with the longitudinal axis of the
lateral incisors were positioned palatally.
Katsnelson et al22 introduced a new simple method to
use a panoramic radiograph to evaluate the position of
impacted maxillary canines. The angulation of the canine
to the occlusion plane was measured using a panoramic
radiograph; if the angulation was greater than 65, it
was 26.6 times more likely to reflect a buccally im-
pacted than a palatally impacted maxillary canine. Their
explanation was that the palatally located tooth could
not have been positioned vertically because the palatal
bone is thin in the sagittal dimension.
Based on the above description, magnification,
angulation and superimposition are simple practical
methods of localizing impacted canine using a single
panoramic radiograph. This study is designed to re-
evaluate the three methods and to compare them with
each other, and then ascertain whether there is a reli-
able method for localizing impacted canines by
viewing a panoramic radiograph.
Materials and methods
This study was designed according to the principles of
the Helsinki Declaration; ethical approval was obtained
from the West China Hospital of Stomatology Institute
Review Board (Chengdu, China). The approval number
is 2011010. Patients with at least one impacted per-
manent maxillary canine who were treated in the
Department of Orthodontics in West China College of
Stomatology were reviewed in this study. The inclusion
criteria for the subjects included: (1) clear digital pano-
ramic radiograph was present; (2) a cone beam CT (CBCT)
image was present; (3) all permanent teeth had erupted
except the impacted canines and/or the third molars. The
exclusion criteria included craniofacial syndromes or
cleft palate.

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:
1. The widest mesiodistal crown dimension of each im-
pacted canine and ipsilateral central incisor was mea-
sured, and the CII values were calculated.
2. The height of the cusp of each impacted canine was
assessed in the vertical plane relative to the ipsilateral
central incisor. The length of the axis of the ipsilateral
central incisor was measured and divided into three
equal zonesapical, middle and coronal. Then the
vertical position of the tip of crown of the impacted
canine by the zones was evaluated (Figure 1).
3. The angulation of the long axis of the impacted
canine to the occlusion plane was measured (a angle,
Figure 2). The occlusion plane was obtained by
connecting the mesiobuccal cusp tips of the two
maxillary first molars.
4. Whether the impacted canine was superimposed on
the root or neck of the central incisor was evaluated.
The examiner was blinded to the canine position and
patient information. All the above measurements were
repeated after 2 weeks by the same examiner, and the
average values were finally adopted. Another researcher
collected the actual positions of impacted canines from
their corresponding CBCT images. The treatment
approaches of the canines impacted buccally and in the
line of the arch are similar, so they were collectively re-
ferred to as buccal canine in this study.
Figure 2 Measurement of a angle in the angulation method. The
occlusion plane was obtained by connecting mesiobuccal cusp tips of
the two maxillary first molars, and the a angle was the angulation of
the long axis of the impacted canine to the occlusion plane
Radiographic localization of impacted canine
S An et al 3 of 6
Figure 3 Experimental design. The localizing methods were decided
based on the vertical categorization of each impacted canine
Three methods were used to localize impacted canines:
magnification, angulation and superimposition. Canines
that were rotated or located in the apical zone were ex-
cluded from the magnification method. The experimental
design is showed in Figure 3.
1. Magnification: based on the research by Chaushu
et al18 and Sudhakar et al,19 in which the vertical
restriction of the impacted canine was considered
as an element of localization, CII 5 1.15 was selected
to be the cut-off point. When the value of CII was
greater than or equal to 1.15, it indicated palatal
location; less than 1.15 indicated buccal location.
Canines that were rotated or located in the apical
zone were excluded. Finally, 48 canines were eligible
for the magnification method.
2. Angulation: based on the research by Katsnelson
et al,22 which demonstrated that the angulation of 65
was the best combination of sensitivity and specificity
to distinguish between the buccally and palatally
impacted canines, a 5 65 was considered as the cut-
off point. When the value of a was less than or equal
to 65, it indicated palatal location; greater than 65
indicated buccal location. Firstly, the angulation
method was used to evaluate the canines that were
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.
The CII values and a angles of palatally and bucally
non-rotated impacted canines were compared using
the MannWhitney U test. Statistical analysis was
Dentomaxillofac Radiol, 42, 20130129
 Radiographic localization of impacted canine
4 of 6 S An et al

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.

Dentomaxillofac Radiol, 42, 20130129


Table 4 Values of sensitivity, specificity, accuracy, positive-likelihood ratio and negative-likelihood ratio
Localization method Sensitivity (%) Specificity (%)
Magnification 68.00 69.57
Angulation 1 34.61 82.61
Angulation 2 28.57 84.91
more variation in the horizontal direction than in the
vertical direction of an image when an object is placed in
random positions about the sharp layer. In this study, the
magnification method (combined vertical restriction and
CII) did not confirm the conclusion of Chaushu et al.18
The diagnostic accuracy rate was approximately 70% and
it was quite different from the 100% in Chaushus study,
which did not exclude the rotated canines. The widest
mesiodistal crown dimension of rotated impacted canine
was not reliable by measurement from a panoramic
radiograph, so the CII value could not be calculated.
The results showed that in the magnification method
(combined vertical restriction and CII), 68.00% of buccal
canines and 69.57% of palatal canines could be localized
correctly. Canines that were rotated or located in the
apical zone were excluded from the magnification
method, and only 48 canines were eligible for this method.
However, in this study, the results of the MannWhitney
U test revealed that in the coronal zone, there was a sta-
tistically significant difference between palatally and buc-
cally impacted canines in relation to CII. It suggested that
further research with an expanded sample size is needed.
The angulation of the long axis of the impacted ca-
nine to the occlusion plane (angulation method) was
also not suitable for localization of impacted canines us-
ing panoramic radiographs.
However, some findings in our study were different
from those in previous reports. Many researchers have
reported that 85% of impacted maxillary canines
were localized palatally, whereas 15% were localized
buccally. 57 However, buccally located canines are more
common among Chinese patients. Wolf and Mattila16
pointed out that the magnification method was much
more accurate in detecting palatally impacted canines
than buccal ones because the magnification was larger
for palatally located canines. In the study by Mason
et al,20 90% of palatal canines and only 10% of buccal
canines could be detected with magnification. The study
by Nagpal et al23 was in accordance with this report. It
seems that the magnification method has some obvious
limitations for Chinese patients. However, in this study,
Table 5 Buccalpalatal positions of the impacted maxillary canines
that were superimposed on the root or neck of the central incisor and
root resorption situation of the central incisors
Superimposing Buccal Central incisor root resorptiona
No central incisor root resorption
Palatal Central incisor root resorption
No central incisor root resorption
a
Central incisor root resorption here defined as the obvious
resorption of the central incisor, which could be detected from the
panoramic radiograph.
Radiographic localization of impacted canine
S An et al 5 of 6
Accuracy (%) Positive-likelihood ratio Negative-likelihood ratio
68.75 2.23 0.3757
58.33 2.07 0.7747
57.84 1.89 0.8412
using the magnification method, 68.00% of buccal canines
and 69.57% of palatal canines could be localized correctly.
The difference in sensitivity between buccal and palatal
canines was not obvious. The results implied that the
magnification method could be used for the population
with higher incidences of buccally impacted canines.
Wolf and Mattila16 observed 47 impacted maxillary
canines projected on the root or neck of the central
incisor and found they were all located palatally.
By coincidence, in our study, we also observed 47 super-
imposing canines, of which 39 were located palatally and
8 were located buccally. Besides, obvious resorption of
the center incisor could be observed in these buccally
located canines. Recently, Jung at el24 reported that
mid-alveolus impacted canines in CBCT were more
frequent in panoramic Sector 4 (the area from the
distal aspect to the midline of the central incisor) and
palatally impacted canines were more frequent in
panoramic Sector 5 (the area from the midline of the
central incisor to the midline of the maxillary arch).
This implied that not every impacted canine projected
on the root or neck of the central incisor was located
palatally, which was in accordance with our finding.
Therefore, the superimposition method can be used only
as an adjunct to the other methods. In particular, this
study showed that most of the canines that were excluded
from the magnification method because of rotation or
being located in the apical zone were superimposed on the
root or neck of the central incisors.
Conclusion
Magnification and angulation methods were not reliable
methods for locating the impacted canines with a single
panoramic radiograph. The magnification method was
more successful than the angulation method. Further
research is needed for the magnification method, while
the image superimposition method could be used as an
adjunct to other methods of localization.
Acknowledgments
The authors are grateful to the X-ray department of
West China College of Stomatology. We would also like
to thank all the orthodontists and their patients who
6 participated in this study.
2
5
34
Funding
This study was supported by the Sichuan Provincial
Foundation (Grant no: 2009SZ0159).
Dentomaxillofac Radiol, 42, 20130129
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6 of 6 S An et al
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