CASE REPORT C

Transposed and impacted maxillary canine with

ipsilateral congenitally missing lateral incisor
Travis Q. Talbot, DDS, MS,a and Arnold J. Hill, DDS, MSb
Salt Lake City, Utah, and Rochester, Minn

T
ooth transposition is an anomaly involving the graph was taken (Fig 1). The radiograph revealed an
positional interchange of 2 teeth. This phenome- ectopically erupting maxillary right canine and first pre-
non is well documented in the literature and molar, a missing maxillary right lateral incisor, and a
most commonly involves the maxillary canine and the peg-shaped maxillary left lateral incisor. The mandibu-
first premolar.1-9 Maxillary canine-first premolar trans- lar permanent dentition was developing and erupting
positions are often accompanied by peg-shaped or con- within normal limits. Because of an arch perimeter defi-
genitally absent lateral incisors.1,3,4,6 The etiology of ciency, the mandibular primary canines had been
maxillary canine-first premolar transpositions appears extracted previously.
to involve genetic influences within a multifactorial At 10 years 10 months of age, complete initial
inheritance model.6 orthodontic records were secured (Figs 2-6). Her med-
If transpositions are detected early enough, intercep- ical history revealed an innocent heart murmur that did
tive treatment may be possible. At later stages, align- not require premedication. The cause of her malocclu-
ment of the teeth in their transposed positions is usually sion was a combination of genetic and environmental
the most practical treatment plan. Movement to their factors.
normal positions in the arch is a possible alternative, but
this may prolong orthodontic treatment, with compro- Diagnosis
mised results because of difficulties in root movement.6 The patient had an Angle Class I malocclusion with
This case report describes the treatment of a patient a deep anterior overbite. She had a straight profile, thin
with a unilaterally transposed maxillary canine and first retrusive lips, a deep mentolabial sulcus, and a promi-
premolar and a congenitally missing lateral incisor. nent soft tissue pogonion. Midlines were coincident.
Other reports have demonstrated premolar substitution Lateral cephalometric evaluation (Table) revealed a nor-
for missing lateral incisors in bilaterally transposed mal maxillary and mandibular anteroposterior skeletal
maxillary canine-first premolar cases.10,11 This case position with a slight skeletal Class III tendency, a nor-
was unique because of the unilateral nature of the trans- mal mandibular plane angle, slightly proclined maxil-
position, the canine impaction, and the extraction deci- lary incisors, and upright mandibular incisors. The
sion. This unusual situation is both educational and panoramic radiograph showed probable transposition of
thought provoking. the maxillary right canine and the first premolar, a miss-
ing maxillary right lateral incisor, and a microdontic
History and etiology maxillary left lateral incisor. Model analysis revealed a
This patient was originally referred by her general moderate arch perimeter deficiency in both arches, an
dentist at 8 years 11 months of age. Moderate lower impinging deep overbite, bilateral end-to-end molar
anterior crowding was noted, and a panoramic radio- relationships, and a retained maxillary primary right lat-
eral incisor.

Specific objectives of treatment

From the Department of Dental Specialities, Division of Orthodontics, Mayo
Clinic, Rochester, Minn. Maxilla
aPrivate practice, Salt Lake City and Provo, Utah. • Accept normal growth changes
bEmeritus staff, Mayo Clinic; private practice, Rochester and Edina, Minn.
Mandible
Reprint requests to: Dr Travis Q. Talbot, 3006 W 13680 S, Riverton, UT 84065;
e-mail, [email protected]. • Accept normal growth changes
Am J Orthod Dentofacial Orthop 2002;121:316-23 Maxillary dentition
Submitted, March 2000; revised and accepted, May 2001. • Minimize incisor retrusion, maintain slight procli-
Copyright © 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 + 0 8/4/120358 nation
doi:10.1067/mod.2002.120358 • Erupt right canine into transposed position
316
American Journal of Orthodontics and Dentofacial Orthopedics Talbot and Hill 317
Volume 121, Number 3

• Substitute right first premolar for lateral incisor

• Substitute left canine for lateral incisor
Mandibular dentition
• Level curve of Spee
• Procline incisors
• Minimize incisor retrusion
Occlusion
• Treat to Class I molar relationship
• Establish canine guidance on right and group guid-
ance on left
• Achieve ideal overbite and overjet
Facial esthetics Fig 1. Pretreatment panoramic radiograph.
• Maintain soft-tissue relationships

Treatment alternatives Treatment progress

After reviewing the initial records, we considered Two years after the initial records were taken, the
various treatment alternatives. One option was to maxillary right canine had not erupted and could be pal-
expand the arches with the goal of treating the patient pated high in the buccal vestibule. Therefore, bands
without tooth extraction. The canine would be accepted were placed on the maxillary first molars, and brackets
in its transposed position, and the missing lateral incisor were placed on the maxillary first premolars and the
would be replaced later with an implant or a fixed pros- central incisors (Fig 7). The impacted canine was
thesis. Other options included different extraction plans, exposed surgically, and a button with a chain was
including extraction of the 4 permanent first premolars placed for traction. A periapical radiograph (Fig 8)
or the 3 first premolars and the maxillary right canine. showed the canine positioned between the 2 premolars.
Both of these options would also necessitate prosthetic The root of the maxillary right first premolar appears
replacement of the missing lateral incisor. Another bifurcated and twisted. An open coil spring was used to
alternative was to extract the mandibular first premolars create additional space to bring the canine into its trans-
and the maxillary left first premolar. The maxillary right posed position in the arch. The remaining teeth in the
premolar could then be substituted for the missing lat- maxillary arch were bonded as they erupted.
eral incisor. Because of the arch perimeter deficiency, Mandibular appliances were added once the impacted
the decision was made to treat the patient with extrac- canine was completely erupted. The maxillary wire
tions. However, the extraction plan and the ultimate sequence was .016 nickel-titanium, .016 × .022 nickel-
treatment goals were different from the options outlined titanium, and .016 × .022 stainless steel. The bracket on
above. the maxillary right first premolar with –7° torque was
bonded upside down to enhance lingual root torque.
Treatment plan Space closure was accomplished with elastomeric
The initial treatment plan was to extract the maxil- chains. The mandibular wire sequence was .016 nickel
lary primary canines, the primary right first molar, the titanium, .016 stainless steel, and .016 × .022 stainless
primary right lateral incisor, the mandibular primary steel. Near the end of treatment, interarch elastics were
first molars, the maxillary permanent left lateral incisor, used to improve the anteroposterior relationship of the
and the mandibular first premolars. The patient was occlusion. Total treatment time was 35 months.
then placed on recall to review the eruptive progress of At the end of treatment, the lingual cusp of the max-
the maxillary right canine and the first premolar. If the illary right first premolar was reduced to improve
maxillary right canine was not making satisfactory esthetics. The patient was encouraged to see her general
progress, the plan was to expose and bond this tooth to dentist to enhance the esthetics with cosmetic bonding
orthodontically encourage its eruption. Partial appli- and gingival recontouring. However, the patient was
ances were to be placed on the maxillary dentition to pleased with the result and refused this procedure. Final
begin eruption of this canine. Full appliances would records and superimpositions are shown in Figures 9
then be added once all permanent teeth became avail- through 15.
able. The maxillary lateral incisors would be replaced
by the maxillary right premolar and the left canine, Results achieved
respectively. All spaces would be closed, finishing with Normal downward and forward growth of the max-
a bilateral Class I molar relationship. illa and mandible occurred, with slight forward growth
318 Talbot and Hill American Journal of Orthodontics and Dentofacial Orthopedics
March 2002

Fig 2. Pretreatment facial photographs.

Fig 3. Pretreatment intraoral photographs.

Fig 4. Pretreatment study models.

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Volume 121, Number 3

Fig 5. Pretreatment headfilm. Fig 6. Pretreatment cephalometric tracing.

at pogonion. The maxillary right canine was brought Table. Cephalometric analysis
into a transposed position with the first premolar. The
Measurement Standard Initial Final
maxillary right first premolar and the left canine were
substituted for the lateral incisors, respectively. The SNA (°) 81.4 80.4 79.5
maxillary incisor angulation and position were main- SNB (°) 77.7 79.5 79.8
tained, and the mandibular incisors were slightly ANB (°) 3.7 0.9 –0.3
Wits (mm) –0.4 –3.2 –1.8
retracted and proclined. The maxillary and mandibular FMA (°) 21.9 23.8 25.3
first molars were extruded and protracted 2.5 mm. SN-GoGn (°) 34.1 34.9 35.2
A Class I molar occlusion was achieved, although the y-axis (°) 59.4 52.1 54.8
left side was not as ideally interdigitated. The final U1 to NA (°) 24.2 27.9 28.7
overbite and overjet were nearly ideal. Midlines were U1 to NA (mm) 4.3 4.2 3.9
U1 to SN (°) 102.0 113.0 114.2
nearly coincident. The patient displayed canine guid- L1 to NB (°) 26.5 15.1 18.7
ance on the right and group guidance on the left. Pre- L1 to NB (mm) 5.0 0.9 0.5
existing soft tissue relationships were maintained, IMPA (°) 95.9 78.7 81.1
although some flattening of the profile occurred mainly U1/L1 (°) 125.5 137.7 133.3
because of growth at pogonion. Satisfactory functional FMIA (°) 65.0 81.9 76.0
Angle of convex 0.0 2.2 –3.0
and esthetic results were achieved, and the patient was G1´-SN-Pg´ (°) 6.7 7.1 2.5
pleased. A maxillary Hawley retainer was to be worn NLA (°) 102.0 107.9 111.3
continuously for 6 months and only at night thereafter. Inc-Stm (mm) 2.0 4.5 2.2
A .030-in lingual bonded retainer was placed on the Pg to NB (mm) 3.0 –0.5 –2.5
mandibular anterior teeth.

DISCUSSION warranted. Extracting the mandibular first premolars

As mentioned previously, this patient could have been would be a popular choice. Because the patient began
treated with several different plans. We chose a unique with an end-to-end molar relationship, extracting the
method of treating this unusual situation; it eliminated mandibular second premolars could have facilitated
the need for prosthetic tooth replacement. molar relationship correction.
The decision whether to extract teeth could be the In the maxillary arch, many would have chosen first
subject of extensive debate. Discussing which teeth to premolar extraction. As previously discussed, this
extract would breed additional controversy. In this case, would have necessitated prosthodontic replacement of
many clinicians would agree that an extraction plan was the missing lateral incisor but could have provided the
320 Talbot and Hill American Journal of Orthodontics and Dentofacial Orthopedics
March 2002

Fig 7. Bands placed on maxillary first molars and brackets on maxillary first premolars and central
incisors.

Fig 8. Periapical radiograph of maxillary right canine.

most ideal esthetic result. However, in contemplating understood the limitations, a treatment plan that would
premolar extraction, one must consider the possibility avoid the eventual need for replacing the missing lateral
of canine ankylosis. In addition, the clinician must be incisor appealed to the parents.
aware of the patient’s chief concerns, goals, and expec- Because of the small size of the maxillary left lateral
tations. In this situation, both the patient and her parents and the position of the adjacent canine, the decision was
were eager to avoid prosthodontics. Although they made to extract the microdontic lateral and replace it
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Volume 121, Number 3

Fig 9. Posttreatment facial photographs.

Fig 10. Posttreatment intraoral photographs.

Fig 11. Posttreatment study models.

322 Talbot and Hill American Journal of Orthodontics and Dentofacial Orthopedics
March 2002

Fig 12. Posttreatment headfilm.

Fig 14. Superimposed cephalometric tracings: initial,

10 years 10 months; final, 16 years 1 month.

Fig 13. Posttreatment cephalometric tracing.

with the canine. Although maintaining the lateral

incisor might have had a more ideal esthetic result,
doing so would have made prosthetic build-up neces-
sary.
Because the decision was to maintain the maxillary
premolars, the position of the right canine and the angu- Fig 15. Posttreatment panoramic radiograph.
lation of the adjacent premolar required acceptance of
the transposition. The canine was successfully brought
into the arch in its transposed position. A satisfactory those of the other premolars. However, as was noted
functional and esthetic relationship was achieved earlier, a periapical radiograph taken 2 years after the
through premolar substitution on the right side and start of treatment (Fig 8) revealed a bifurcated root
canine substitution on the left. The posttreatment structure, with the roots appearing twisted. This mal-
panoramic radiograph (Fig 15) shows that the roots of formed root architecture may have been a result of the
the maxillary right first premolar were shorter than transposed canine developing near the premolar roots.
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Volume 121, Number 3

Radiographic assessment of the premolar throughout transposed canines in a sample of orthodontic patients. Br J
treatment showed little root resorption. The roots of the Orthod 1998;25:203-8.
2. Weeks, EC, Power SM. The presentations and management of
maxillary right first premolar and left canine were
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etiology. Angle Orthod 1996;66:147-52.
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additional dentistry to achieve optimal esthetic and Orthod 1993;63:99-109.
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her parents were very pleased with the result, and ment. J Am Dent Assoc 1983;107:746-8.
prosthodontic replacement of the congenitally missing 9. Shapira Y. Transposition of canines. J Am Dent Assoc 1980;100:
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