Canine transmigration: comprehensive literature review and report of 4 new Australian cases

Canine transmigration: comprehensive literature review and report of 4 new Australian cases Julijana Vuchkova, BSc, BDSc, PhD,a and Camile S. Farah, BDSc, MDSc, PhD, GCEd(HE), FRACDS(Oral Med), FIAOO, FICD,b Herston and Brisbane, Queensland, Australia UNIVERSITY OF QUEENSLAND AND QSCAN RADIOLOGY CLINICS

Canine transmigration is a rare dental anomaly unique to the mandibular arch, involving intraosseous migration of the unerupted tooth across the midline. Currently, there is a lack of consensus on the definition of transmigration. This report suggests a unified definition of transmigration, that being when a canine has crossed the midline by more than half its length. Numerous publications reporting mandibular canine transmigration therefore cannot be considered as being truly transmigrated. Here we undertake a comprehensive review of the literature, and report 4 new cases of transmigrated mandibular canines, 2 of which present with unique features. One case shows a vertically positioned transmigrated canine, whereas the other shows a horizontally transmigrated canine underlying an impacted canine. Furthermore, this cohort is the first to be reported in an Australian population. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e46-e53)

Intraosseous migration of unerupted teeth is a rare dental condition of horizontal tooth movement and impaction. It occurs mainly in the mandible and involves primarily the lateral incisors, canines, and second premolars. The affected teeth usually remain in the same side of the mandibular arch, being referred to as ectopic or impacted. The canine is the only tooth shown to migrate across the midline to the contralateral side of the mandible, an anomaly defined as “transmigration.” Many authors consider transmigration of a canine to have occurred with only the tip of the cusp crossing the midline. Hence, there is inconsistency in the reporting of transmigrated canines. There should be a general consensus definition of canine transmigration, that being (as proposed by Javid1) of an impacted canine that crosses the midline for at least half its length. Canine transmigration is of significant importance in dentistry, creating orthodontic, surgical, and interceptive problems. There are many reports on mandibular canine transmigration; however, the etiology and pathogenesis of this condition are still unclear. Furthera

Lecturer, Oral Medicine & Oral Pathology, The University of Queensland, School of Dentistry & UQ Centre for Clinical Research, Herston, Queensland, Australia. b Consultant in Oral Medicine & Oral Pathology, The University of Queensland, School of Dentistry & UQ Centre for Clinical Research, Herston, Queensland, Australia; Consultant Oral Pathologist, Qscan Radiology Clinics, Brisbane, Queensland, Australia. Received for publication Aug 3, 2009; returned for revision Dec 13, 2009; accepted for publication Dec 17, 2009. 1079-2104/$ - see front matter © 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2009.12.031

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more, there are many reports on mandibular canine transmigration, which, according to Javid’s definition,1 cannot be considered as true cases of canine transmigration. The aim of this report is to provide a comprehensive review of the literature, differentiating true cases of canine transmigration from impacted or ectopic canines, and to report 4 new Australian cases of transmigrated mandibular canines. To the best of our knowledge, this is the first report of canine transmigration in an Australian population. CASE REPORTS In a radiographic survey of 60,000 orthopantomograms (OPGs) taken over a period of 6 years (from 2004 to 2009), 4 cases of transmigrated canines were observed. All OPGs were from an Australian population in the state of Queensland that had undergone routine radiographic imaging for either orthodontic or pathological purposes. The transmigrated canines were detected coincidentally at the time of diagnosis. Table I presents the demographic and radiographic features of all 4 cases. Fig. 1, A and B, shows the computed tomography (CT) scan and 3-dimensional (3D) reconstruction of case 1, whereas Figs. 2, 3, and 4 show the OPG of cases 2, 3, and 4 respectively. All patients were women, and the age at initial diagnosis varied from 18 to 67 years. In 3 of the 4 cases, the mandibular left canine had undergone transmigration (Figs. 1, 2, and 3). In 2 of the 3 cases, the deciduous canine was retained (Figs. 1 and 2). In 1 case, the transmigrated 33 was accompanied by a horizontally impacted 43, positioned directly above and parallel to the transmigrated 33 (Fig. 3). To the best of our knowledge, this is the second published case (the first case was reported by Javid1) of a transmigrated canine accompanied by an impacted canine originating from the contralateral side. In 1 of the 4 cases, the mandibular right canine had

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Table I. Cases of canine transmigration observed in an Australian population Case

Age

Sex

Canine

Mandibular position

Inclination

Associated pathology

Other observations

1 2 3 4

18 67 67 54

Female Female Female Female

33 33 33 43

Lower border (44-46) Lower border (45-47) Lower border (42-44) Between incisors (31-32)

Horizontal Horizontal Horizontal Vertical

Nil Nil Nil Nil

73 retained 73 retained 43 horizontally impacted Nil

Fig. 3. Orthopantomogram showing a transmigrated 33 lying inferior to an impacted 43 in a 67-year-old female.

Fig. 1. Panoramic slice (A) and 3D reconstruction (B) of a CT Dentascan showing a transmigrated 33 and retained 73 in an 18-year-old female. The transmigrated canine is positioned on the labial aspect of the mandible, with the crown lying adjacent to the right mental foramen (B). No pathology was associated with the transmigrated canine as clearly demonstrated in (A).

Fig. 2. Orthopantomogram showing a transmigrated 33 and retained 73 in a 67-year-old female. The lower second permanent premolars (35 and 45) were previously extracted.

undergone transmigration, and differs from the other 3 cases in that the canine was positioned vertically (unerupted, between the 32 and 31) rather than horizontally (Fig. 4). This finding is unique, and to the best of our knowledge, has not been reported previously. All cases were asymptomatic, and no associated pathology was observed.

Fig. 4. Orthopantomogram showing a transmigrated 43 positioned vertically between the 31 and 32 in a 54-year-old female.

DISCUSSION Transmigration is a rare dental anomaly affecting mandibular canines only. Review of the literature (Tables II and III) shows 185 publications reporting transmigrated canines, with the first case being reported by Thoma.2 A precise definition of canine transmigration is lacking; however, we suggest there should be a general consensus definition (as proposed by Javid1) that a tooth be classified as transmigrated when more than half of the length of the tooth has crossed the midline. Consequently, a large portion of publications cannot be regarded as true cases of transmigration, as the authors of these publications have described cases of impacted canines rather than transmigrated canines. This comprehensive review of the literature shows that only 86 of 185 published cases can be truly regarded as transmigrated canines. A similar observation was made by Pippi and Kaitsas,40 who reported that only 65 of the 179 published cases could be considered as true

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Table II. Chronological order of published cases showing true canine transmigration (as per Javid’s1 definition) Age

Sex F:M

Position of canine crown

Thoma2 Caldwell3 Bruszt4

1954 1955 1958

NM 31 NM

NM 1:0 1:1

1 1 2

Stafne5 Ando6 Kaufman7

1963 1964 1967

NM 11 19

NM 0:1 1:0

Fiedler8 Pratt9 Tarsitano10

1968 1969 1971

16 19 NM

Black11 Heiman12 Miranti13 Howard14

1973 1973 1974 1976

Barnett15

Inclination of canine

— — —

1:0 1:0 1:1

First molar First molar Between/in front of incisors

Horizontal Horizontal NM

NM 1:0 1:0

1 1 1

— — —

0:1 0:1 0:1

Canine First premolar Canine

Horizontal Horizontal Oblique

NM 1:0 1:0

1:0 0:1 NM

1 1 3

— — —

0:1 1:0 3:0

Horizontal NM Horizontal (3)

23 30 17 12-18

0:1 1:0 1:0 3:0

1 1 1 3

— — — —

1:0 1:0 0:1 1:2

1977

24

1:0

1

—

1:0

Second premolar In front of incisors Canine (2) First molar (1) First molar First premolar Canine Canine (1) First premolar (2) Next to canine

Abbott16

1980

62

1:0

1

—

1:0

Between canine and incisor

NM

Hebda17 Zvolanek18 Shapira19 Nashashibi20 O’Carroll21 Javid1

1980 1981 1982 1984 1984 1985

21 31 8 24 28 13-52

0:1 1:0 1:0 0:1 1:0 8:5

1 1 1 1 1 13

— — — — — —

1:0 1:0 0:1 0:1 0:1 NM

Canine First molar Canine Canine Second premolar Up to first molar

Oblique Horizontal Horizontal Oblique Horizontal Horizontal (3)

NM NM 1:0 NM 1:0 11:2

Grover22 Dhooria23 Broadway24 Ripari25 Vichi26 Shanmuh.27 Joshi28 Kharbanda29 Costello30 Al-Waheidi31

1985 1986 1987 1988 1991 1991 1994 1994 1996 1996

27 17 15 9 29-42 20-52 14 11-12 19-33 15

0:1 1:0 1:0 0:1 3:0 1:1 1:0 1:1 1:1 1:0

1 1 1 1 3 2 1 1 2 1

— — — — — — — — — —

0:1 0:1 1:0 1:0 1:2 1:1 1:0 2:0 1:1 1:0

Canine Premolars Second premolar Canine Up to premolar Up to premolar First molar Up to first premolar Up to first molar Up to canine

Horizontal NM Oblique NM NM Oblique Horizontal Horizontal Horizontal Horizontal

1:0 NM 1:0 NM NM 2:0 1:0 2:0 2:0 1:0

Horizontal Horizontal Horizontal Oblique 64° (1) Horizontal (2) NM

Nature AS:S

1:0 1:0 3:0 1:0 0:1 NM NM NM 1:0

Associated pathology/features Radiolucency around crown — Canine erupting on opposite side (2) (between incisors) (1) (in front of incisors) (1) — — Canine erupting on opposite side (between lateral incisor and canine) Eruption cyst Retained deciduous canine Odontoma (1) Retained deciduous canine (2) Retained deciduous canine Retained deciduous canine — Retained deciduous canine (1) Canine erupting on opposite side (labial to canine) Canine erupting on opposite side (between lateral incisor and canine) — — Anterior crowding — Retained deciduous canine Retained deciduous canine Impacted contralateral canine (3) Clinically missing canine Dentigerous cyst (1) Chronic fistula (3) Retained deciduous canine — Retained deciduous canine Retained deciduous canine Retained deciduous canine (1) Odontoma (2) Retained deciduous canine Retained deciduous canine (1) Retained deciduous canine (2) Impacted contralateral canine (1)

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Uni/Bilateral Uni Bi

Year

First author

2007 2008 Sumer39 Pippi40

Alejos-Algarra

The features summarized include age (years at time of diagnosis), sex (M ⫽ male, F ⫽ female), unilateral (uni) or bilateral (bi) occurrence, the canine affected (L ⫽ left, R ⫽ right), most distal position of the transmigrated canine crown, inclination of the transmigrated canine, symptomatic nature (AS ⫽ asymptomatic, S ⫽ symptomatic), and other pathology or features associated with the transmigrated canine. NM denotes Not Mentioned; numbers in parentheses denote number of cases; — denotes Nil.

1:0 NM Horizontal Horizontal (3) Oblique (3) First premolar Second premolar 1:0 6:0 — — 1 6 1:0 6:0

Canine Up to canine Canine Up to third molar 0:1 0:2 0:1 1:1 — — — — 1 2 1 2 1:0 1:1 1:0 0:2 2003 2003 2004 2006 Aydin35 Camilleri36 Aydin37 Auluck38

17 8-12 22 25

Up to premolars NM — 2 1:1 19-20 2002 Mupparapu34

23 14-32

1:0 2:0 1:0 2:0

NM

NM

Horizontal Erupted (1) Oblique (1) Horizontal (1) Horizontal Horizontal Horizontal Horizontal Up to first molar 10:4 — 14 9:5 13-23 2001 Joshi33

1998

16-28

1:4

5

—

4:1

Up to first molar

Horizontal (4) Oblique (1)

3:2

Retained deciduous canine (2) Impacted contralateral canine (1) Follicular cyst (1) Retained deciduous canine (10) Cyst (3) Retained deciduous canine (1) Odontoma (1) — Retained deciduous canine — Retained deciduous canine (extracted and placed implant) Retained deciduous canine Retained deciduous canine (5)

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Year First author

Table II. Continued

Age

Sex F:M

Uni/Bilateral Uni Bi

Canine L:R

Position of canine crown

Inclination of canine

Nature AS:S

Associated pathology/features

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canine transmigrations, although they did not specify the cases that they reviewed (in comparison with Tables II and III). Making a diagnosis of canine transmigration can be difficult in younger patients, because the stage of transmigration cannot be determined at the time of diagnosis, and this may pose a problem. A canine that is impacted at first viewing may later progress and become transmigrated. This has been shown in a single study by Ando et al.,6 whereby an impacted canine in a 7-year-old child was followed by serial radiographs over several years to show that it eventually transmigrated at the age of 11 years and 10 months. Others have tried to reproduce this study, but have been unsuccessful.14,41,43 Although they were able to show some changes and progress in tooth impaction, they did not demonstrate true canine transmigration. Migration of a canine within the mandible apparently commences in the early mixed dentition stage (age 6 to 8 years), with the greatest amount of tooth movement occurring before completion of root development.19,51 This issue is therefore only likely to affect the correct diagnosis when dealing with very young children, and does not apply to most published cases. It is unlikely that impacted canines viewed in older individuals will later become transmigrated. Hence, by strict adherence to the definition of transmigration, only those canines that have truly transmigrated at the time of diagnosis can be reported as cases of this condition. In 2002, Mupparapu34 proposed a classification system for transmigrated canines relating to different patterns of axial inclination and position of the affected tooth relative to the midline (Type 1 to Type 5). The classification system, however, does not apply to truly transmigrated canines, as the different patterns of transmigration (Type 1 to Type 4) refer to the inclination of impacted or ectopic canines instead. However, in more than 65% of true transmigration cases the canines were horizontal, and according to this classification system, would all fall in the same category (Type 5). The remaining 35% could not be categorized according to this classification. Transmigration is usually a unilateral process, involving a single mandibular canine. Cases of bilateral transmigration have been reported, involving both mandibular canines. Review of the literature, however, shows that in almost all of these cases the canines did not cross the midline by more than half of their length, and therefore can only be regarded as impacted or ectopic. There is only one published case involving both mandibular canines whereby one canine had undergone transmigration, whereas the second mandibular canine was merely impacted.31 Hence, true cases of bilateral transmigration have not been reported to date.

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Uni/Bilateral Uni Bi

First author

Year

Age

Sex F:M

Position of canine crown

Inclination of canine

Nature AS:S

Greenberg41 Howard14

1976 1976

8 11-20

0:1 3:2

1 5

— —

1:0 2:3

Oblique Oblique (30-75°)

1:0 NM

— Retained deciduous canine (1)

— 1 1

1 — —

1:1 0:1 0:1

Lateral incisor Central incisor (2) Lateral incisor (3) Midline Lateral incisor Between central incisors

Joshi42 Kerr43 Sofat44

1982 1982 1983

19 12 20

1:0 1:0 0:1

Horizontal Oblique Erupted

1:0 1:0

NM 0:1 0:1

1 1 —

— — 1

0:1 1:0 1:1

Lateral incisor Lateral incisor Midline

NM Oblique NM

NM NM NM

25 9-40 13 14 9-13

1:0 10:6 0:1 1:0 3:2

1 11 1 1 5

— 1 — — —

1:0 7:6 1:0 0:1 3:2

Midline Up to incisors Incisor Lateral incisor Central incisors

NM NM NM Horizontal NM

NM NM NM 1:0 NM

1995 1996

16 9-20

1:0 4:0

— 2

1 1

1:1 3:1

Midline Up to incisors

Horizontal Horizontal

1:0 4:0

Joshi33

2001

9-21

9:5

10

4

9:9

Up to incisors

Horizontal

NM

Mupparapu34

2002

17-69

6:1

7

—

NM

Up to incisors

NM

Aydin35

2003

10-24

0:2

1

1

1:2

Up to incisors

Camilleri36 Aydin37

2003 2004

14 11-70

0:1 1:6

1 7

— —

1:0 5:2

Up to lateral incisor Up to incisors

Oblique (6) Horizontal (1) Erupted (2) Horizontal Oblique (1) Oblique Oblique (7)

Nil Retained deciduous canine Retained deciduous canine (canine erupted between central incisors) Retained deciduous canine Retained deciduous canine Retained deciduous canine (1) between apices of central incisors — Retained deciduous canine (10) Retained deciduous canine — Retained deciduous canine (3) Cyst (1) Nil Cyst (3) Crowding (1) Retained deciduous canine (12) Cyst (5) Odontoma (1) Retained deciduous canine (3) Dentigerous cyst (1)

Vaskova45 Nashashibi20 Jalili46

1984 1984 1986

14 19 17

Zvolanek47 Vichi26 Mitchell48 Joshi28 Wertz49

1986 1991 1993 1994 1994

Kuftinec50 Al-Waheidi31

Ryan51 Shapira52 Auluck38

2005 2005 2006

12 16 20-40

1:0 0:1 1:1

1 1 2

— — —

1:0 0:1 1:1

Central incisors Up to lateral incisor Midline

Horizontal Horizontal Oblique (1) Erupted (1)

1:0 1:0 2:0

0:2 1:0 NM

Associated pathology/features

Retained deciduous canine (2) Dentigerous cyst (1) Retained deciduous canine Retained deciduous canine (1) Pericoronal radiolucency (1) Pericoronal radiopacity (1) Follicle enlargement (1) Crown resorption ⫹ radiolucency (1) Hemifacial microsomia ⫹ cleft palate Impacted contralateral canine Retained deciduous canine (2)

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Table III. Chronological order of published cases NOT considered to be showing true canine transmigration (as per Javid’s1 definition)

Central incisors 6:6 — 12 6:6 15-57 2008 Aras54

Camilleri

The features summarized include age (years at time of diagnosis), sex (M ⫽ male, F ⫽ female), unilateral (uni) or bilateral (bi) occurrence, the canine affected (L ⫽ left, R ⫽ right), most distal position of the transmigrated canine crown, inclination of the transmigrated canine, symptomatic nature (AS ⫽ asymptomatic, S ⫽ symptomatic), and other pathology or features associated with the transmigrated canine. NM denotes Not Mentioned; numbers in parentheses denote number of cases; — denotes Nil.

NM

5:0

Horizontal (1) Oblique (4) NM Up to incisors 3:2 — 5 1:4 13-54 2007 Sumer39

2007

13

1:0

1

—

1:0

Lateral incisor

Oblique

1:0

Retained deciduous canine Impacted lateral incisor (parallel to impacted canine) Retained deciduous canine (2) Dentigerous cyst (1) Retained deciduous canine (2)

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Year First author

Table III. Continued

Age

Sex F:M

Uni/Bilateral Uni Bi

Canine L:R

Position of canine crown

Inclination of canine

Nature AS:S

Associated pathology/features

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Neurological evidence of canine transmigration was initially provided by Caldwell3 and later confirmed by Bruszt.4 Both these authors described cases of mandibular canines that had migrated to the contralateral side (and in one case erupted), but derived their innervation from the original side. This was determined by lack of anesthesia of the transmigrated tooth at extraction, following an inferior dental nerve block on the migrated side. Burszt4 went on to confirm this by showing complete anesthesia of the migrated tooth following inferior dental nerve block on the contralateral side. Review of the literature shows that the left canine is predominantly affected compared with the right (1.6:1), and females are affected almost twice as frequently as males (1.8:1). The cases presented in this article are in accordance with these international observations: all 4 cases were female and 3 of them involved transmigration of the left canine, whereas 1 showed transmigration of the right canine. Reasons for this are not understood. Findings are generally coincidental or associated with investigations of missing permanent canines. Furthermore, there is a large variation in the age group of cases reported, most likely related to the primary reason for investigation. Members of the younger population are those predominantly seeking orthodontic treatment, and the older group would be those undergoing radiographic screening for other purposes. The cases presented here were also of a wide age group, ranging from 18 to 67 years of age. Etiological factors listed are many and varied, including ectopic growth of the tooth bud, axial inclination of erupting canine, retention or premature loss of a deciduous canine, inadequate eruption space, supernumerary teeth, excessive length of crown, genetic factors, endocrine disorders, trauma, diet, and intrauterine defects.19,40,51 Some cases have been associated with pathological features such as cysts, tumors, or odontomas, believed to cause malposition of teeth if located in the path of eruption. Table II, however, shows that these are rare findings. In 2 of 3 cases presented here, the transmigrated canine was associated with a retained deciduous canine. Many other authors have reported retained deciduous canines associated with transmigrated canines, and in fact, this has been observed in 44% of the published cases. It is not possible to discern, however, if any of these features are the cause or consequence of transmigrated canines. Although a single etiologic factor has not been identified, Pippi and Kaitsas40 proposed a theory on the pathogenesis of intraosseous migration of canines, involving 2 factors: a strong and extended eruptive force caused by lasting root formation, and a pericoronal osteolytic area caused by widening of the follicular space. The authors propose that following impaction,

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these 2 factors can cause the anomalous movement of the canine inside the mandible. The osteolytic area (relating to inflammatory stimuli and associated secretion of signal molecules) is believed to represent a site of less resistance, toward which the tooth moves while root formation is taking place. Hence, the simultaneous occurrence of these 2 events is believed to create the intraosseous movement of the canine (in the opposite direction to the root) until a mechanical obstacle is reached (such as the cortical bone), or when the pericoronal osteolytic area dissipates. The precise interplay of the previously mentioned events is obviously speculative, and several other factors are thought to be facilitating, including the very spongy bone tissue of the mandible. It is for this reason that many authors, including Peppi and Kaitsas,40 believe that only mandibular canines can transmigrate, as the maxillary canines cannot transmigrate through the dense palatine bone, and that the intermaxillary suture acts as a barrier to eruptive forces.33,40,52 According to the literature, there is no doubt that this phenomenon is unique to the mandible. Although the incidence of maxillary canine impactions is approximately 20 times greater than that of mandibular canine impactions,51 true transmigrated maxillary canines have not been reported to date.32,35,51,52,54 Although some publications32,51,54 have shown cases where a portion of the maxillary canine crown has crossed the midline, these cases cannot be considered as transmigrated according to the proposed definition, as the canines did not cross the midline by more than half their length. Diagnosis of transmigration cases most commonly occurs on OPGs. In fact, reports of transmigrated canines began with the use of OPG. However, the downside of using the OPG solely is the inherent problem of distortion. On an OPG, canines may appear to have transmigrated by more than half their length, when in fact they have not. In some cases, this has been confirmed with supplementary views such as occlusal radiographs. Case 1 in this series was identified using a CT scan following a routine OPG. Although it is not always feasible or necessary to perform such supplementary scans, it highlights the importance of accurate interpretation of the position of impacted canines and hence accurate diagnosis of transmigrated canines. With the use of such scans, it is also easier to determine whether the canine is located on the buccal or lingual aspect of the mandible. This is obviously important in decisions regarding interceptive treatment. CONCLUSION This article provides a comprehensive review of the literature, differentiating true cases of canine transmigration from impacted or ectopic canines, and reports 4

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