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BILATERAL TRANSMIGRATION OF IMPACTED MANDIBULAR CANINES
A
'Ii
A CASE REPORT
BILATERAL TRANSMIGRATION
OF IMPACTED MANDIBULAR CANINES MLADEN M. KUFTINEC, D.M.D., D.STOM., SC.D.; YEHOSHUA SHAPIRA, D.M.D., M.S.; ODED NAHLIELI, D.D.S.
Case reports have described displacement and migration of teeth in the upper and lower dental arches, but migration of a tooth across the mandibular midline is rare. The authors describe an extremely rare case of bilater-
al transmigration of impacted permanent canines across the midline of the mandible.
nO 1971, Tarsitano and colleagues used the term "transmigration" to describe the displacement and migration of an impacted tooth across the midline to the opposite side of the jaw.1 Later, Javid' expanded the definition to include cases in which more than half of the tooth had passed through the midline. Such displacement may occur spontaneously or as a result of a localized pathologic lesion, such as an odontoma or a dentigerous cyst.3 Although impacted canines are far less common in the mandible than in the maxilla, occurring at a ratio of 1-to-20,4 the dental literature includes several case reports of unilateral transmigration of impacted mandibular canines."," However, bilateral transmigration of impacted mandibular canines across the midline and along the lower border of the mandible is extremely rare. Only a few such cases have been reported.2,"'-4 Migrated canines typically remain impacted,'5 but they may erupt ectopically at the midline'6 or on the opposite side of the arch.'720 CASE REPORT
A 16-year-old girl was referred to our clinic for orthodontic consultation and treatment. Her medical history was non-contributory. On examination, the clinican noted the absence of both lower permanent canines and the upper left permanent canine. The maxillary left deciduous canine was present. A panoramic radiograph revealed three impacted canines, one on the left side of the maxillary arch and two in the mandibular arch. The mandibular canines had nearly crossed the symphyseal midline. The left canine was lying above the right one, which was adjacent to the lower border of the mandible (Figure 1). Both canines seemed to be rotated with their lingual surfaces facing occlusally. Both were situated on the anterior surface of the incisor roots. TREATMENT
This patient's treatment plan included surgical removal of both mandibular canines, removal of the maxillary deciduous canine, surgical exposure of the impacted maxillary canine and use of orthodontic traction to bring that tooth into the maxillary arch. 1022 JADA, Vol. 126, July 1995
CLINICAL POACTICE-
Figure 1. Panoramic radiograph showing the horizontally impacted right and left mandibular canines across the midline, one on top of the other. Note the impacted maxillary permanent left canine and the retained deciduous one.
To remove the mandibular canines, we administered local anesthesia on both sides of the mandible, raised a mucoperiosteal flap and removed the thin labial cortical bone (Figure 2). The left canine was the first to be extracted because it was lying superiorly to the right canine. The right canine was situated close to the lower border of the mandible. After smoothing the rough bony margins, we sutured the flap. Healing was uneventful. We scheduled a second surgery to expose and bond the impacted maxillary canine. Unfortunately, the patient has refused any further surgical or orthodontic intervention and treatment has been discontinued. DISCUSSION
The mandibular permanent canine is the only tooth in the dental arch reported to migrate across the symphyseal midline to the contralateral side. In doing so, the tooth usually travels along the labial side of the incisor roots. It has been found to migrate as far as the roots of the first molar on the opposite side.21 Similar to previously reported cases of bilateral transmigration, 11-2 our case presents the impacted canines crossing the midline one above the other. It appears that they are stopped and unable to migrate past the lateral incisor roots on the opposite side. This is probably due to the limited space available at the curve between the anterior and posterior regions of the mandible. We know of no case of bilateral transmigration in which canines have moved to contralateral sides with their crown tips distal to the lateral incisor roots region.
w -: - s Figure 2. The surgically exposed left canine is rotated with its lingual surface facing occlusally.
Some authors have described cases in which a unilaterally impacted canine has transmigrated and erupted on the contralateral side.'17'1920'22 However, we found no similar reports describing eruption of bilaterally transmigrated canines. CONCLUSION
Even under clinical and radiologic scrutiny, certain dental anomalies may not be detected. Whenever permanent teeth cannot be accounted for (in the absence of trauma), dentists should remain alert to the possibility of a dental anomaly and consider use of non-routine diagnostic methods. The case presented here-transmigration of the mandibular canines-illustrates the value of this approach. Treatment options are quite limited for the anomaly described in this case; most transmigrated teeth must be surgically removed. Failure to detect such teeth, however, could lead to serious damage to adjacent teeth and surrounding bone. o The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinions or official policies of the American Dental _II~ Association or its subsidiaries.
Dr. Kuftinec is professor and chairman, Department of Orthodontics. New York University College of Dentistry, 345 E. 24th Street, New York 0010. Address reprint requests to Dr. Kuftinec.
1. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of non-erupted mandibular canines: report of cases. JADA 1971;82:1,395-7. 2. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14(6):547-9. 3. Shapira Y, Mischler WA, Kuftinec MM. The displaced mandibular canine. ASDC J Dent Child 1982;49(5):362-4. 4. Rohrer A. Displaced and impacted canines. Int J Orthod Oral Surg 1929;15:1,002-20. 5. Fiedler LD, Alling CC. Malpositioned mandibular right canine: report of a case. J Oral Surg 1968;26:405-7. 6. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3(2):117-21. 7. Greenberg SN, Orlian AI. Ectopic movement of an unerupted mandibular canine.
JADA, Vol. 126, July 1995
1023
-CLINICAL PRACTICE
Membership Benefits YOU! As a member of the American Dental Association you will have access to:
Dr. Shapira Is a visitIng professor, De-
pertinent of Orthodontics, New York University College of Dentistry, New York. He Is also a
facuity
member, Department
of a toll-fres li
abilitym
of Ortlhodontis, Maurice and Gabriela
cover
Goidschleger Schooi
acc pt c g od saA cO mie, tients; qualify for a Prudential Home Mortgage or membership in the Alaska a
ier
an
ri *.. -1a
*t
PArtcipathe inexcellente indrsurancepas
Padr
ing cical
is
sur
c
a s
availabe
a
ail
thoug
system
Monembersn-e
ef
m,
eA
,
and
cluding professional liability coverage, office overhead expense, disability in-
issues, antitrust law, other federal law issues, and insurance contract ap-
addressing critical issues such as OSHA, health system reform, DEA, and National Data Bank regulations. !PA' "L7W, V i 9tC W'
procedures and methodologies, and news of important events concerning
Surgery, Barziia, Hospital Medicai Center, Ashkelon, Israel.
of Dentai Medicine, Tei Aviv University,
JADA 1976;93:125-8. 8. Shanmuhas untharam P. Trans-
Tei Aviv,
migration of perma-
Israel.
nent mandibular canines. Case report.
Aust Dent J 1991;36:209-13. 9. Vichi M, Franchi L. Contributo clinico sulla transmigrazione del canino inferiore permanente. Minerva Stomatol 1991;40:579-89. 10. Kerr WJS. A migratory mandibular canine. Br J Orthod 1982;9:111-2. 11. Cowman SC, Wooton WR. Bilateral impaction of mandibular canines. NZ Dent J 1979;75:113-4. 12. Joshi MR, Daruwala NR, Ahuja HC. Bilateral transmigration of mandibular canines. Br J Orthod 1982;9(l):57-8. 13. Mehta DS, Mehta MJ, Mrgesh SB, Thakur S. Impactions of bilateral mandibular canines in criss-cross fashion. J Indiana Dent Assoc 1986;58(12):549-51. 14. Gadgil RM. Impacted mandibular anteror teeth. Oral Surg Oral Med Oral Pathol 1986;61(1): 106. 15. Shapira Y, Kuftmnec MM. Intraosseous transmigration of mandibular caninesReview of the literature and treatment options. Compend Contin Educ Dent (In press). 16. Brezniak N, Ben-Yelluda A, Shapira Y. Unusual mandibular canine transposition: a case report. Am J Orthod Dentofacial Orthop 1993; 104:91-4. 17. Pindborg JJ. Pathology of the dental
hard tissues. Philadelphia: Saunders; 1970:66-70. 18. Abbott DM, Svirsky JA, Yarborough BH. Transposition of the permanent mandibular canine. Oral Surg Oral Med Oral Pathol
dental meeting; fulfill continuing education requirements while seeing a shwcs of clnia an tehia advne from aron th globe.
Dr. Nahieli Is a faculty member and an attending surgeon, Department of Orai and Maxiiiofaciai
1980;49:97.
19. Bruszt P. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1958;11:89-90. 20. Pratt RJ. Migration of canine across the mandibular midline. Br Dent J 1969;126:463-4. 21. Caldwell JB. Neurological anatomy associated with extreme malposition of the mandibular canine. Oral Surg Oral Med Oral Pathol 1955;8:484-7.
22. Kaufman AY, Buchner A. Trans-
migration of mandibular canine. Oral Surg Oral Med Oral Pathol 1967;23:648-50.
Enjoy full privileges, including mail order and photocopy services at the most complete facility of its kind in the world.
When You Join the ADA, The ADA Joins You! I
For nore information, pleas call (312) 440-2500 1024 JADA, Vol. 126, July 1995
'Ii
A CASE REPORT
BILATERAL TRANSMIGRATION
OF IMPACTED MANDIBULAR CANINES MLADEN M. KUFTINEC, D.M.D., D.STOM., SC.D.; YEHOSHUA SHAPIRA, D.M.D., M.S.; ODED NAHLIELI, D.D.S.
Case reports have described displacement and migration of teeth in the upper and lower dental arches, but migration of a tooth across the mandibular midline is rare. The authors describe an extremely rare case of bilater-
al transmigration of impacted permanent canines across the midline of the mandible.
nO 1971, Tarsitano and colleagues used the term "transmigration" to describe the displacement and migration of an impacted tooth across the midline to the opposite side of the jaw.1 Later, Javid' expanded the definition to include cases in which more than half of the tooth had passed through the midline. Such displacement may occur spontaneously or as a result of a localized pathologic lesion, such as an odontoma or a dentigerous cyst.3 Although impacted canines are far less common in the mandible than in the maxilla, occurring at a ratio of 1-to-20,4 the dental literature includes several case reports of unilateral transmigration of impacted mandibular canines."," However, bilateral transmigration of impacted mandibular canines across the midline and along the lower border of the mandible is extremely rare. Only a few such cases have been reported.2,"'-4 Migrated canines typically remain impacted,'5 but they may erupt ectopically at the midline'6 or on the opposite side of the arch.'720 CASE REPORT
A 16-year-old girl was referred to our clinic for orthodontic consultation and treatment. Her medical history was non-contributory. On examination, the clinican noted the absence of both lower permanent canines and the upper left permanent canine. The maxillary left deciduous canine was present. A panoramic radiograph revealed three impacted canines, one on the left side of the maxillary arch and two in the mandibular arch. The mandibular canines had nearly crossed the symphyseal midline. The left canine was lying above the right one, which was adjacent to the lower border of the mandible (Figure 1). Both canines seemed to be rotated with their lingual surfaces facing occlusally. Both were situated on the anterior surface of the incisor roots. TREATMENT
This patient's treatment plan included surgical removal of both mandibular canines, removal of the maxillary deciduous canine, surgical exposure of the impacted maxillary canine and use of orthodontic traction to bring that tooth into the maxillary arch. 1022 JADA, Vol. 126, July 1995
CLINICAL POACTICE-
Figure 1. Panoramic radiograph showing the horizontally impacted right and left mandibular canines across the midline, one on top of the other. Note the impacted maxillary permanent left canine and the retained deciduous one.
To remove the mandibular canines, we administered local anesthesia on both sides of the mandible, raised a mucoperiosteal flap and removed the thin labial cortical bone (Figure 2). The left canine was the first to be extracted because it was lying superiorly to the right canine. The right canine was situated close to the lower border of the mandible. After smoothing the rough bony margins, we sutured the flap. Healing was uneventful. We scheduled a second surgery to expose and bond the impacted maxillary canine. Unfortunately, the patient has refused any further surgical or orthodontic intervention and treatment has been discontinued. DISCUSSION
The mandibular permanent canine is the only tooth in the dental arch reported to migrate across the symphyseal midline to the contralateral side. In doing so, the tooth usually travels along the labial side of the incisor roots. It has been found to migrate as far as the roots of the first molar on the opposite side.21 Similar to previously reported cases of bilateral transmigration, 11-2 our case presents the impacted canines crossing the midline one above the other. It appears that they are stopped and unable to migrate past the lateral incisor roots on the opposite side. This is probably due to the limited space available at the curve between the anterior and posterior regions of the mandible. We know of no case of bilateral transmigration in which canines have moved to contralateral sides with their crown tips distal to the lateral incisor roots region.
w -: - s Figure 2. The surgically exposed left canine is rotated with its lingual surface facing occlusally.
Some authors have described cases in which a unilaterally impacted canine has transmigrated and erupted on the contralateral side.'17'1920'22 However, we found no similar reports describing eruption of bilaterally transmigrated canines. CONCLUSION
Even under clinical and radiologic scrutiny, certain dental anomalies may not be detected. Whenever permanent teeth cannot be accounted for (in the absence of trauma), dentists should remain alert to the possibility of a dental anomaly and consider use of non-routine diagnostic methods. The case presented here-transmigration of the mandibular canines-illustrates the value of this approach. Treatment options are quite limited for the anomaly described in this case; most transmigrated teeth must be surgically removed. Failure to detect such teeth, however, could lead to serious damage to adjacent teeth and surrounding bone. o The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinions or official policies of the American Dental _II~ Association or its subsidiaries.
Dr. Kuftinec is professor and chairman, Department of Orthodontics. New York University College of Dentistry, 345 E. 24th Street, New York 0010. Address reprint requests to Dr. Kuftinec.
1. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of non-erupted mandibular canines: report of cases. JADA 1971;82:1,395-7. 2. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14(6):547-9. 3. Shapira Y, Mischler WA, Kuftinec MM. The displaced mandibular canine. ASDC J Dent Child 1982;49(5):362-4. 4. Rohrer A. Displaced and impacted canines. Int J Orthod Oral Surg 1929;15:1,002-20. 5. Fiedler LD, Alling CC. Malpositioned mandibular right canine: report of a case. J Oral Surg 1968;26:405-7. 6. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3(2):117-21. 7. Greenberg SN, Orlian AI. Ectopic movement of an unerupted mandibular canine.
JADA, Vol. 126, July 1995
1023
-CLINICAL PRACTICE
Membership Benefits YOU! As a member of the American Dental Association you will have access to:
Dr. Shapira Is a visitIng professor, De-
pertinent of Orthodontics, New York University College of Dentistry, New York. He Is also a
facuity
member, Department
of a toll-fres li
abilitym
of Ortlhodontis, Maurice and Gabriela
cover
Goidschleger Schooi
acc pt c g od saA cO mie, tients; qualify for a Prudential Home Mortgage or membership in the Alaska a
ier
an
ri *.. -1a
*t
PArtcipathe inexcellente indrsurancepas
Padr
ing cical
is
sur
c
a s
availabe
a
ail
thoug
system
Monembersn-e
ef
m,
eA
,
and
cluding professional liability coverage, office overhead expense, disability in-
issues, antitrust law, other federal law issues, and insurance contract ap-
addressing critical issues such as OSHA, health system reform, DEA, and National Data Bank regulations. !PA' "L7W, V i 9tC W'
procedures and methodologies, and news of important events concerning
Surgery, Barziia, Hospital Medicai Center, Ashkelon, Israel.
of Dentai Medicine, Tei Aviv University,
JADA 1976;93:125-8. 8. Shanmuhas untharam P. Trans-
Tei Aviv,
migration of perma-
Israel.
nent mandibular canines. Case report.
Aust Dent J 1991;36:209-13. 9. Vichi M, Franchi L. Contributo clinico sulla transmigrazione del canino inferiore permanente. Minerva Stomatol 1991;40:579-89. 10. Kerr WJS. A migratory mandibular canine. Br J Orthod 1982;9:111-2. 11. Cowman SC, Wooton WR. Bilateral impaction of mandibular canines. NZ Dent J 1979;75:113-4. 12. Joshi MR, Daruwala NR, Ahuja HC. Bilateral transmigration of mandibular canines. Br J Orthod 1982;9(l):57-8. 13. Mehta DS, Mehta MJ, Mrgesh SB, Thakur S. Impactions of bilateral mandibular canines in criss-cross fashion. J Indiana Dent Assoc 1986;58(12):549-51. 14. Gadgil RM. Impacted mandibular anteror teeth. Oral Surg Oral Med Oral Pathol 1986;61(1): 106. 15. Shapira Y, Kuftmnec MM. Intraosseous transmigration of mandibular caninesReview of the literature and treatment options. Compend Contin Educ Dent (In press). 16. Brezniak N, Ben-Yelluda A, Shapira Y. Unusual mandibular canine transposition: a case report. Am J Orthod Dentofacial Orthop 1993; 104:91-4. 17. Pindborg JJ. Pathology of the dental
hard tissues. Philadelphia: Saunders; 1970:66-70. 18. Abbott DM, Svirsky JA, Yarborough BH. Transposition of the permanent mandibular canine. Oral Surg Oral Med Oral Pathol
dental meeting; fulfill continuing education requirements while seeing a shwcs of clnia an tehia advne from aron th globe.
Dr. Nahieli Is a faculty member and an attending surgeon, Department of Orai and Maxiiiofaciai
1980;49:97.
19. Bruszt P. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1958;11:89-90. 20. Pratt RJ. Migration of canine across the mandibular midline. Br Dent J 1969;126:463-4. 21. Caldwell JB. Neurological anatomy associated with extreme malposition of the mandibular canine. Oral Surg Oral Med Oral Pathol 1955;8:484-7.
22. Kaufman AY, Buchner A. Trans-
migration of mandibular canine. Oral Surg Oral Med Oral Pathol 1967;23:648-50.
Enjoy full privileges, including mail order and photocopy services at the most complete facility of its kind in the world.
When You Join the ADA, The ADA Joins You! I
For nore information, pleas call (312) 440-2500 1024 JADA, Vol. 126, July 1995