CASE REPORT

Horizontally impacted maxillary premolar and

bilateral canine transposition
Demetrios J. Halazonetis
Athens, Greece

This case report describes the treatment of a patient whose maxillary left first premolar was impacted horizontally,
and both maxillary canines were transposed relative to the first premolars. The patient was treated without
extractions, and both canines were brought to their correct positions in the maxillary arch. Treatment mechanics
during the various stages are discussed. (Am J Orthod Dentofacial Orthop 2009;135:380-9)

M
axillary canine-first premolar transposition ectopic eruption of tooth 13 (FDI tooth numbering) and
is an orthodontic anomaly involving the the impaction of teeth 23 and 24, as shown by a
positional interchange of the canine and first panoramic radiograph (Fig 3). His medical and dental
premolar.1 Although relatively rare, with an incidence histories were unremarkable. Facial assessment showed
of approximately 0.3%,2 it is the most common type of a slightly convex profile with protruding lips. Clinical
transposition (58%-70%),3,4 followed by the maxillary examination of the occlusion showed a Class I dental
canine-lateral incisor transposition. Its etiology is con- relationship. The maxillary deciduous canines and the
sidered to be genetic and multifactorial,1,5,6 but envi- maxillary left first deciduous molar were present. The
ronmental factors might also contribute.4 Familial oc- maxillary right permanent canine was erupting in an
currence and greater prevalence in females have been ectopic position between the 2 premolars. The maxil-
observed.3,7 Bilateral expression of the transposition is lary left lateral incisor was in crossbite, and there was
common (11%-27%); otherwise, in unilateral cases, the a slight midline diastema. The mandibular arch showed
left side seems to be more frequently affected,3,7,8 rotations but no crowding. The maxillary central inci-
although this might be sex dependent.4 The condition is sors had enamel decalcification bands, but the parents
associated with other dental anomalies, especially hy- could not recall any childhood incident to explain them.
podontia and peg-shaped lateral incisors.3,4,7,8 Cephalometric assessment showed a mild Class II
Treatment of maxillary canine-first premolar trans- skeletal pattern with proclined mandibular incisors
position depends on the stage of development of the (Table I).
anomaly at diagnosis and the position of the roots of the
involved teeth. Usually, space in the dental arch is TREATMENT OBJECTIVES
sufficient, so extraction of 4 first premolars, which Ideally, the treatment objectives would include full
would easily resolve the situation, is seldom the pre- resolution of the malocclusion, with correct positioning
ferred choice.3 Leaving the teeth in the transposed of the transposed canines and the impacted premolar in
order is indicated when the roots are completely trans- the dental arch. However, this would have entailed a
posed. This solution has a minor esthetic disadvantage long treatment with significant risks of failure. Alter-
but is significantly easier and faster, and carries less native treatment plans with less ambitious objectives
risk of failure than trying to correct the order of the were presented to the patient for consideration.
teeth.
TREATMENT ALTERNATIVES
DIAGNOSIS
The following treatment alternatives were consid-
The patient was a white boy, aged 12 years 10 ered.
months (Figs 1 and 2). The main concern was the
1. Extraction of all first premolars (thus resolving the
Assistant professor, Department of Orthodontics, School of Dentistry, Univer- transpositions and the impaction of tooth 24) to
sity of Athens, Athens, Greece.
Reprint requests to: Demetrios J. Halazonetis, 6 Menandrou St, Kifissia 145 61, establish a Class I molar and canine relationship.
Greece; e-mail, [email protected]. 2. Extraction of teeth 14 and 24 and movement of the
Submitted, October 2006; revised and accepted, December 2006. maxillary posterior teeth anteriorly to establish a
0889-5406/$36.00
Copyright © 2009 by the American Association of Orthodontists. Class I canine relationship and a Class II molar
doi:10.1016/j.ajodo.2008.09.019 relationship.
380
American Journal of Orthodontics and Dentofacial Orthopedics Halazonetis 381
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Fig 1. Pretreatment facial and intraoral photographs. The maxillary deciduous canines and
deciduous left first molar are still present. Note the discoloration of the enamel of the maxillary
central incisors.

3. Extraction of tooth 24. Tooth 14 would be moved these factors were favorable toward resolution of the
mesially to take the position of the canine, and transposition, because they would allow mesial move-
tooth 13 would be left in the transposed position. ment of the canine without the need for excessive
On the left side of the maxillary arch, the canine buccal movement that would risk fenestration and
would be moved mesially to its proper position, and gingival recession.3,9 However, the buccal frenum was
the molar would be finished in a Class II relation- immediately mesial to the canine crown and extended
ship. downward. This could hinder mesial movement and
4. Nonextraction treatment and movement of both might cause recession.
maxillary first premolars mesially, leaving both Tooth 23 seemed to be directly above the root of the
maxillary canines transposed. first premolar. It was not possible to ascertain its
5. Nonextraction treatment and resolution of both buccolingual position from the panoramic or the ceph-
transpositions to achieve a Class I canine and molar alometric radiograph. An occlusal radiograph would
relationship. have been useful, but it was decided to take a dental
In considering these treatment alternatives, the computed tomograph (CT) instead to better assess the
following factors were taken into account. position of both canines relative to the premolars and
Tooth 13 was erupted, but it was still at a high also to see the extent of the alveolar bone on the buccal
position relative to the 2 premolars. The right first surface of the canine roots.10 The CT (Fig 4) showed
premolar was rotated at approximately 45°. Both of that the crown of tooth 23 was positioned buccally to
382 Halazonetis American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 2. Pretreatment dental casts.

Table I. Selected cephalometric measurements before

and after treatment
Measurement Pretreatment Posttreatment

SNA (°) 75 74
SNB (°) 71 70
ANB (°) 4 4
SNPg (°) 71 70
Pogonion to NB (mm) 0 1
Wits appraisal (mm) 3 4
Occlusal plane to SN (°) 21 19
SN to GoGn (°) 37 38
Fig 3. Pretreatment panoramic radiograph. The maxil- Upper incisor to NA (°) 20 25
lary left first premolar is horizontally impacted with Upper incisor to NA (mm) 4 6
bending of the root apex. Lower incisor to NB (°) 34 35
Lower incisor to NB (mm) 8 9
Interincisal angle (°) 121 116
the root of tooth 24, which was short and showed Lower incisor to GoGn (°) 106 107
bending at the apex. Overjet (mm) 3 2
The clinical assessment of the face and the cepha- Overbite (mm) 3 1
lometric measurements indicated that retraction of the
lips would be beneficial. However, there was no crowd-
ing, so a large part of any extraction space would have lip prominence. Any extraction plan would need min-
to be closed by mesial movement of the posterior teeth. imal anchorage.
Furthermore, growth of the nose and the chin was Movement of the canines to their proper location
expected to improve the profile by reducing the relative would necessitate movement along the buccal aspect of
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Fig 4. CT images of the maxilla. The images represent consecutive slices taken from the level just
above impacted tooth 24 (A) down to the level just below it (F). Note that the alveolar process is
wider near the apices of the teeth than near the cervices. Tooth 23 is positioned buccally to the root
of the premolar (B and C). The palatal root of tooth 14 is at the same mesiodistal position as the
canine, and only the buccal root is in true transposition (A-F).

the alveolar process, running the risk of gingival Extraction of the mandibular premolars and mesial
recession and fenestration. The buccal frenum was also movement of the posterior teeth might increase the
a consideration, as mentioned above. chance of normal eruption of the third molars.11,12
In general, finishing a patient in a Class II molar However, it was considered too early to reliably predict
relationship does not seem to be a great concern, if their fate.
good intercuspation is achieved. However, leaving the
canine and the premolar transposed might cause func- TREATMENT PROGRESS
tional occlusal problems and would probably necessi- After discussing the above considerations with the
tate grinding the premolar’s palatal cusp. patient and his parents, it was decided to attempt
Esthetic concerns included the final gingival status treatment the fifth plan. They preferred it because it
of the canines, if brought to their correct positions, and avoided extractions and should result in all teeth in their
the lip prominence of the facial profile, if nonextraction correct positions. The risk of not being able to achieve
treatment were attempted. Leaving the canines trans- the desired goal and the prolonged treatment time were
posed could also result in suboptimal dental esthetics. understood and accepted by the patient and the parents.
384 Halazonetis American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 5. Progress at 2 months: A, protraction of tooth 13 in a mesial and upward direction; B, the
maxillary first premolar was exposed, after extraction of the deciduous teeth. The buccal surface of
tooth 24 is visible here.

Fig 6. Progress at 3 months: A, maxillary view of the transpalatal arch. Tooth 14 is being retracted
from the palatal side to rotate it and move the buccal root palatally; B, sectional mechanics to
upright tooth 24 and move the root palatally.

Fig 7. Progress at 5 months: A, tooth 13 has been brought mesially against the lateral frenum; B,
a cantilever was bonded to tooth 24 for palatal movement of the root.

Fixed appliances (0.018-in slot) were used in both palate, thus allowing mesial canine passage without
arches. At the start of treatment, a transpalatal arch was excessive buccal displacement (CT images in Fig 4).
placed for anchorage and derotation of the maxillary Sectional mechanics were used for uprighting tooth
molars. After 2 months of treatment, tooth 13 was 24 (Fig 6). Special care was taken to move the root of
protracted in a slightly upward direction (Fig 5, A). This this premolar toward the palate to give space to the
direction of traction ensured that the canine would canine. The premolar was also rotated to place the
remain high, in the wider part of the alveolar process, wider side of the root against the canine and make more
until correction of the transposition. Meanwhile, tooth space in the alveolar process. At 5 months of treatment
24 was exposed, and the deciduous teeth of the maxil- (Fig 7), tooth 13 was positioned almost mesially to
lary left quadrant were extracted (Fig 5, B). Tooth 14 tooth 14 and against the lateral frenum. A few months
was retracted from the palatal aspect (Fig 6, A). This later, tooth 24 had been rotated to 90° and uprighted,
would move the premolar distally and palatally to give with the root in a palatal position (Fig 8). The maxillary
more space to the canine. It would also exacerbate the right deciduous canine was extracted, and the perma-
tooth’s rotation, bringing the buccal root toward the nent canine was moved toward its proper position.
American Journal of Orthodontics and Dentofacial Orthopedics Halazonetis 385
Volume 135, Number 3

Fig 8. Progress at 11 months: palatal cantilever to upright tooth 24 by bringing the root distally. The
root was in a palatal position, and the tooth was rotated by 90° to allow more room for the canine.

RESULTS
Both canines were brought into their correct posi-
tions in the dental arch. The horizontally impacted
premolar was also corrected. Final occlusion was good,
except for the left canine, which finished in an almost
end-to-end relationship. Periodontal examination of the
canines did not show increased pocket depth. The
gingival margins on the buccal side were higher than
normal, but no root surface was exposed.
Fig 9. Progress at 24 months: tooth 13, after being Facial esthetics had no appreciable changes, except
brought to its correct position between the premolar for the expected growth-related ones.
and the lateral incisor, is being rotated. The final cephalometric values are shown in Table
I, and the initial and final tracings are shown superim-
Protraction of the right canine had resulted in rotation. posed on the anterior cranial base in Figure 15. The
Derotation and uprighting were performed by using an patient had a vertical growth pattern but no appreciable
overlay nickel-titanium archwire (Fig 9). downward mandibular rotation. Dental changes bet-
At 30 months of treatment (Fig 10), tooth 13 was ween the initial and final tracings were minimal. The
upright and positioned in the dental arch but needed mandibular incisors remained at the same labial incli-
torquing of the root to the palatal aspect. This was nation as before treatment. The nose had grown signif-
initially attempted with a sectional archwire, using only icantly, resulting in a less protrusive profile outline in
the premolar as anchorage, because the premolar the lip area.
needed opposite torque to return the root toward the Radiographic examination near the end of treatment
buccal aspect. Meanwhile, tooth 23 showed no signs of (Fig 12) had shown blunting of the apices of the
spontaneous eruption, so it was exposed. Fixed appli- maxillary incisors and a short root of the maxillary left
ances were placed in the mandibular arch. The maxil- first premolar, but this was mainly a result of arrested
lary left first premolar was rotated and torqued to the root formation from the initial position of this tooth
correct position. Further torquing of the maxillary right rather than root resorption after treatment.
canine was accomplished by a sectional 0.017 ⫻ A bonded mandibular permanent retention appli-
0.025-in copper-nickel-titanium wire running from the ance was placed immediately after debonding. A re-
molar to the canine and twisted by 180° (Fig 11). movable appliance was used in the maxillary arch.
A progress panoramic radiograph was taken at 51
months of treatment (Fig 12). Moderate root resorption
of the maxillary incisors and the left first premolar were DISCUSSION
noted. Tooth 23 had been brought into the dental arch. This patient had a combination of bilateral canine
Torquing of the root was accomplished with the same transposition, premolar horizontal impaction, and ca-
technique as on the maxillary right canine. Total nine impaction. The transposition of the left side was
treatment time was 5 years 2 months (62 months). Final complete: both the crown and the root apex were
records are shown in Figures 13 and 14. Patient displaced. The transposition on the right side was of the
cooperation was excellent; oral hygiene was good to root apex only, because the premolar was horizontally
moderate. impacted so that the crown faced distally and abutted
386 Halazonetis American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 10. Progress at 30 months: A, torquing of tooth 13 against 14 via a sectional archwire; B,
exposure and traction of the maxillary left canine. Note tooth 24 at 90° rotation.

Fig 11. A and B, at 39 months, torquing of tooth 13 via sectional .017 ⫻ .025 copper-nickel-titanium
wire twisted 180°. Meanwhile, tooth 23 was being brought down to the arch, and tooth 24 was being
rotated to the correct position. C, At 41 months, after torquing of tooth 13.

Although the treatment goals were achieved, the

final result was not ideal: (1) the occlusion on the left
side, although good at the molars, was cusp-to-cusp at
the canines; (2) the gingival level at the labial aspect of
the canines was higher than desired; (3) fenestrations or
reduced alveolar bone coverage on the labial aspect of
the canines was possible but could not be ascertained
without a new CT; (4) treatment time was extended,
possibly contributing to the root blunting observed at
Fig 12. Progress panoramic radiograph at 51 months. the end; and (5) the mandibular incisor proclination was
not corrected. In retrospect, one could argue that a
treatment plan that included extraction of the 4 first
the second premolar. Transposition patients are usually premolars could have prevented these problems. How-
treated by preserving the order of the teeth. This patient
ever, if not for the transpositions and the impactions,
had certain characteristics that made resolution of the
extractions would not have been considered; the patient
transposition feasible: (1) the right canine had not fully
would probably not even have requested orthodontic
erupted and remained at a high level and in a wide area
treatment. Therefore, although maxillary extractions
of the alveolar process; (2) the palatal root of the right
first premolar was in its proper position, with the could be beneficial, mandibular extractions might cre-
transposition mainly involving the buccal root, as ate other difficulties, such as the danger of reducing the
shown by the CT images; and (3) the left canine could profile excessively.
easily be brought into position, if the impacted premo- In determining the optimum treatment plan, it might
lar was moved out of the way. The left first premolar be helpful to tabulate the advantages and disadvantages
was the greatest challenge, because its root had to be of each plan. This was done in Table II. It can be seen
moved in a wide arc, from the initial mesial position, that no treatment plan was without problems. The final
first to the palatal position to allow eruption of the choice depends on the weight that we and our patients
canine, then to the buccal side. This movement had assign to each factor under consideration. This is a
biomechanical difficulties with the risk of root resorp- difficult and subjective decision that must be made with
tion. limited and vague information.
American Journal of Orthodontics and Dentofacial Orthopedics Halazonetis 387
Volume 135, Number 3

Fig 13. Photographs after removal of appliances.

A literature search on transposition patients who started, and the amount of gingiva on the crown was
were treated by correcting the order of the teeth resulted limited because of its high position. At the end of
in only a few reports.9,13,14 The recommended approach treatment, there was approximately 1 mm of attached
was similar to that followed for this patient—move the gingiva, and the lateral frenum was close to the gingival
premolar palatally to create space to allow the mesial margin, but periodontal conditions were good. The
translation of the canine. impacted premolar did not present any difficulties
Correcting a maxillary canine-first premolar trans- regarding periodontal status. Exposure of the crown
position is certainly not a fast treatment option. Other was done with an apically repositioned flap when the
cases in the literature were treated for more than 4 years deciduous teeth were extracted. Final photographs and
(Maia and Maia13 reported treatment duration of 57 clinical examination showed identical conditions to the
months, and Kuroda and Kuroda14 reported 49 months). contralateral premolar. The left canine was also im-
This patient had the extra complication of the horizon- pacted at the beginning of treatment and was exposed.
tally impacted premolar and took even longer; this At the time of exposure, the tip of the crown was labial
invariably causes some compromises in the final detail- to the root of the first premolar and just below the
ing of the occlusion. mucogingival junction. A simple excisional uncovering
The lateral frenum on the right side did not hinder of the crown tip was performed (Fig 10, B). Although
the mesial movement of the canine, as originally an apically positioned flap might have provided better
thought. Before starting treatment, we searched the gingival conditions, the final situation is similar, if not
literature and posted a relevant question at the Elec- better, to the right side. Criteria for deciding on the
tronic Study Club for Orthodontists, but little helpful proper exposure method to optimize periodontal con-
information was found. Periodontal considerations are ditions were reviewed and suggested by Kokich.15
important in cases of impacted teeth or teeth that are The system for torquing the canines, wih a twisted
labially positioned and have insufficient attached gin- .017 ⫻ .025-in copper-nickel-titanium wire proved to
giva. Tooth 13 was already erupted when treatment be efficient and easy to apply. The CT images also were
388 Halazonetis American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 14. Posttreatment dental casts.

especially useful for planning the required tooth move-

ments. Cone-beam CT is now increasingly used and
recommended for diagnosis and treatment planning of
impacted teeth.16,17 Root resorption and the extent of root
coverage by alveolar bone (especially on the buccal side
of the transposed canine root) are things to look for.
During treatment, it is recommended to keep the
canine at a high level in the alveolar process, so that the
root remains within the wider bony area and is not
displaced labially to create a fenestration. The premolar
can be rotated by 90°, so that the narrower dimension of
the root (mesiodistal) faces the canine and provides
more space. For the same reason, the premolar can be
torqued so that the root moves palatally.
CONCLUSIONS
Understanding the biologic principles and master-
ing the biomechanics enable us to carry out challenging
tooth movements. The feasibility, however, of such
movements should not be the sole criterion that dictates
Fig 15. Initial and final tracings superimposed on the the treatment plan. This case report shows a difficult
anterior cranial base. case that could have been treated in several ways, and
American Journal of Orthodontics and Dentofacial Orthopedics Halazonetis 389
Volume 135, Number 3

Table II. Advantages and disadvantages of treatment plans for this patient
Treatment plan

1 2 3 4 5
Extraction Extraction Extraction Nonextraction; Nonextraction;
of 4 of 14 and of 24; retain retain transposition correct transposition
premolars 24 transposition order order order

Factor under consideration

Teeth lost ⫺4 ⫺2 ⫺1 ⫹ ⫹
Third molar prognosis ⫹? ⫺? ⫺? ⫺? ⫺?
Treatment duration ⫹ ⫹ ? ⫺ ⫺
Treatment difficulty ⫺ ⫹ ⫺ ⫺ ⫺
Occlusion, functional problems ⫹ ⫹ ⫺ ⫺ ⫹
Profile esthetics ⫺ ⫹ ⫹ ⫹ ⫹
Incisor proclination ⫹ ⫺ ⫺ ⫺ ⫺
Risk of fenestrations ⫹ ⫹ ⫹ ⫹ ⫺
Risk of root resorption ⫹ ⫹ ⫹ ⫹ ⫺

A plus sign indicates a positive outcome and a minus sign the opposite.

probably the most difficult way was selected. One 9. Bocchieri A, Braga G. Correction of a bilateral maxillary
wonders whether the patient would have been served canine-first premolar transposition in the late mixed dentition.
Am J Orthod Dentofacial Orthop 2002;121:120-8.
better by aiming for an easier result instead of strug-
10. Preda L, La Fianza A, Di Maggio EM, Dore R, Schifino MR,
gling to achieve an ideal and complete dentition. Campani R, et al. The use of spiral computed tomography in the
However, the result certainly justifies the original localization of impacted maxillary canines. Dentomaxillofac
decision. Radiol 1997;26:236-41.
11. Kim TW, Årtun J, Behbehani F, Artese F. Prevalence of third
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