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Transmigration of mandibular cuspids: review of published reports and description of nine new cases
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British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Review
Transmigration of mandibular cuspids: review of published reports and description of nine new cases Rosa-María Díaz-Sánchez a , Raquel Castillo-de-Oyagüe a , María-Ángeles Serrera-Figallo a , Pilar Hita-Iglesias b , José-Luis Gutiérrez-Pérez a , Daniel Torres-Lagares a,∗ a b
Oral Surgery Department, Dental School, University of Seville Oral Surgery Department, University of Michigan
Accepted 10 January 2016
Abstract We have reviewed all documented cases of mandibular canine transmigration from1951 (when to our knowledge the first case was published) to 2015, and retrospectively evaluated nine further sequential cases of transmigrating mandibular canines in one hospital by analysing relevant data, including patients’ age and sex, presence of retained deciduous canines, radiographic changes, coexisting systemic diseases, and treatment. Transmigration of a mandibular canine is a rare anomaly of eruption, and extraction is the usual treatment. The nine new patients were aged from 16 -48 years, eight of the transmigrated canines were unilateral, and one patient had them bilaterally. They were all completely impacted. Four were retained primary teeth, and five exfoliated primary canines. Eight had no associated radiographic or clinical abnormalities, while one patient had an associated odontoma. Six mandibular canines were removed and three kept under observation. Early detection of transmigrated canines gives the opportunity to monitor their development, which may improve prognosis and treatment. © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Canine; Transmigration; Impaction; Tooth; Maleruption
Introduction Dental retention occurs when a permanent tooth remains unerupted for more than a year after the expected time of eruption. With the exception of third molars, retention is rare.1 The intraosseous migration of impacted teeth is an unusual dental anomaly, the origin2–5 and developmental process of which,6–10 are still obscure. The migration of a canine within the jaws is thought to start during early, mixed, dentition, so that most movement occurs before the root is formed.11–13 When part of an impacted tooth crosses the dental midline, its atypical ∗ Corresponding author at: Dental School – University of Seville, C/ Avicena s/n 41009, Sevilla (SPAIN). Tel.: +954481129; fax: +954481157. E-mail address: [email protected] (D. Torres-Lagares).
position is described as “transmigration.”9–12 Although this was first described in 1951,1 the definition and understanding were not standardised until much later. Various expressions such as “anomalous tooth,”2 “poorly positioned tooth.”3 “displaced tooth,”4 “unusual tooth,”5 “dislodged tooth”,6 and “poorly erupted tooth”7 have been applied to transmigrated teeth. In 1964, Ando et al.8 introduced the current term “transmigration,” and used “transmigrated tooth” to refer to the pattern of eruption. In 2002, Mupparapu9 proposed a classification for intraosseous transmigration and ectopic eruption of mandibular canines according to their migratory pattern and position in the jaw with respect to the dental midline, and described five types (Table 1). This categorisation has facilitated communication among clinicians. Although transmigration was thought initially to affect mandibular canines exclusively,9–11
http://dx.doi.org/10.1016/j.bjoms.2016.01.010 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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Table 1 Patterns of intraosseous transmigration and ectopic eruption of mandibular canines.9
Table 2 Documented cases of lower transmigrated canines from January 1951 to April 2015 (n=353 teeth in 319 patients).
Mupparapu pattern
Corresponding position of the mandibular canine
Variable
Type 1
Positioned mesioangularly across the midline with the jawbone, labial or lingual to the anterior teeth, and with the crown of the tooth crossing the midline. Horizontally impacted near the inferior border of the mandible below the apices of the incisors. Erupting either mesial or distal to the opposite canine. Horizontally impacted near the inferior border of the mandible below the apices of either the premolars or molars on the opposite side. Positioned vertically in the midline (with the long axis of the tooth crossing the midline) despite the state of eruption.
Type 2 Type 3 Type 4
Type 5
the theory was disproved in 2004 when Aydin and Yilmaz12 described a case of a transmigrating maxillary cuspid. Given that there is still uncertainty surrounding the procedure of dental migration, the purpose of this paper was to review the documented cases of mandibular canine transmigration since the first description in 1951 to date, and to report a series of nine new cases.
Site of transmigration (patients): Unilateral Bilateral Patients’ age range (years) Sex of patient: Male Female Not stated Condition of teeth: Erupted Not erupted Not known Patterns of teeth: 1 2 3 4 5 Not known Associated conditions of teeth: Yes No Not known
Number (%) 283 (89) 36 (11) 7-70 134 (42) 168 (53) 17 (5) 13 (4) 314 (89) 26 (7) 112 (32) 63 (18) 31 (9) 47 (13) 12 (3) 88 (25) 44 (13) 269 (76) 40 (11)
Patients, material, and methods We reviewed all reports of cases and series of mandibular canine transmigration published in the PubMed and MEDLINE electronic databases from January 1951 to April 2015. Papers available in English, French, German, Italian, and Spanish were considered. The search was made between March and April 2015. The key words / Medical Subject Headings (MeSH) used with different combinations were: mandibular canine transmigration, mandibular canine impaction, impacted tooth, dental migration, transmigrant canine, misplaced canine, maleruption, displaced canine, and eruption anomaly. We reviewed all the documented cases of mandibular canine transmigration in the languages specified. As this is a rare entity, we found no clinical trials on the subject. We were unable to do a meta-analysis because of the heterogeneity of the data. All cases of mandibular canine transmigration retrieved were therefore included in the revision and the following characteristics were assessed: age and sex of the patients, pattern of transmigration (Mupparapu classification),9 unilateral or bilateral location, presence of retained deciduous canines, eruption or lack of eruption of the transmigrated canines, pathological changes, associated anomalies, and treatment given. Retrospective clinical evaluation of nine new cases We retrospectively analysed the records of nine consecutive patients who presented with mandibular canine
transmigration to the Department of Oral Surgery of the University of Seville, Spain. This observational study was conducted in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki (as revised in Tokyo, 2004) and the Spanish Law 14/2007 of 3 July for Biomedical Research. All the participants were told about the purpose and process of the investigation. The assessment was made with the understanding and written consent of each subject and according to the abovementioned principles. Approval of the Ethics Committee of the University of Seville was obtained after their ethics board had independently reviewed the study protocol. Patients’ anonymity was preserved. All patients had preoperative panoramic radiographs taken, and the Mupparapu classification was applied in each case.9
Results The review of published reports found that 83 papers that described 319 patients with 353 transmigrated mandibular canines had been published since 1951 (Table 2).1–83 The radiographic and clinical data of our nine new cases are summarised in Table 3. Some radiographs are shown in Figs. 1 and 2. We found that mandibular canine transmigration was more common in women (6/9, Table 3) - a pattern that is in line with previous reports that indicated a female:male ratio between 2:1 and 3:1.49,55 The age range of the patients in the
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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Table 3 Summaries of the nine new cases. Case No
Age (years)
Sex (M/F)
Diagnosis
Type of MCT
Position
Treatment
1
20
F
Lower left canine included
Left - 4
2
26
F
Lower right canine included
Right - 5
Extraction and primary lower left canine maintained Extraction
3
18
M
Left - 4
4
48
F
5
16
M
Upper left lateral incisor included Bilateral canines included Lower left canine included
Fully impacted, caudal to the apices of canine and premolars Fully impacted, vertical position, cusp crossing the midline Fully impacted Apical to the mandibular incisors Associated odontoma in the canine position
6
58
M
Lower left canine included
Left - 5
Apical to the mandibular incisors
7
21
F
Lower right canine included
Right - 4
8
47
F
Lower right canine included
Right - 2
Close proximity to the roots of the first lower molar Apical to the mandibular incisors
Periodic monitoring, refused extraction Extraction and simultaneous removal of odontoma Extraction. Loss of space because of the absence of the primary canine Extraction
9
22
Fe
Lower right canine included
Right - 4
Bilateral 2 Left - 4
Close proximity to the inferior left border of the mandible
Extraction
Periodic radiographic and clinical examination Periodic radiographic and clinical examination
MCT=mandibular canine transmigration.
Fig. 1. Cases 1 to 3. (A) Case 1: Lower left transmigrated canine. Note the deciduous tooth. (B) Case 2: Lower right impacted canine crossing the midline. We assumed the Mupparapu Type 5 pattern of transmigration.9 (C) Case 3: 18-year-old patient with lower left transmigrated canine.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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Fig. 2. Cases 7 to 9. (A) Case 7: Transmigration of the lower right impacted canine with the deciduous tooth still in the arch. (B) Case 8: Lower right impacted canine positioned horizontally. (C) Case 9: Lower right impacted canine positioned horizontally in a patient with cri du chat syndrome.
present study (16-58 years) (Table 3) was in agreement with that found in the review (7-70 years) (Table 2).1–85 While transmigration used to be a unilateral process involving a single mandibular canine,10,29,42,48,59,69 36 of the reported cases (11%) presented with bilateral transmigration (Table 2). Among our nine patients only one had bilateral disease (Table 3).
Discussion Mandibular canine transmigration is an atypical dental abnormality in which an unerupted mandibular canine migrates
and crosses the mandibular midline.69 This unusual condition is most often diagnosed by chance during a routine radiograph.78,79 The most common clinical signs are overretention of the deciduous canine and absence of the permanent canine in the dental arch after its physiological period of eruption.73,77 Mandibular canine transmigration is therefore thought to evolve at an early age, between 6 and 8 years, before the root has formed completely.24,53 Several hypotheses have been suggested to account for it: premature loss of deciduous teeth,24 osteodental discrepancy,51 displacement of the canine crypt,3 agenesis of the lower lateral incisors,44 endocrine pathology and heredity,24 local trauma,4 and oral disease.21,25,34,44,49 Some investigators
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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have considered that the canine tooth germ anterior to the mandibular incisors may have been displaced toward the contralateral side with mandibular facial growth,15 while others have suggested that an abnormally strong eruptive force directed the canine to an aberrant position.43 The exact cause remains unknown. This rare condition preferentially affects the mandibular dental arch.36,59,62,67,68 Aydin et al.55 reported frequencies of transmigration for maxillary and mandibular canines of 0.1%, and 0.2%, respectively. The most common theory to account for its relative infrequency suggests that the shorter anatomical distance between the roots of the maxillary incisors and the floor of the nasal fossa, and the large roots of the maxillary incisors, are responsible.12,55 The higher cross-sectional area of the mandibular anterior region compared with that of the anterior maxilla might also be a reason for the higher incidence.55 In 2002, Mupparapu proposed a five-tier classification for mandibular canine transmigration (Table 1).9 We suggest that the Mupparapu Type 5 could be incorporated into Type 1 because of its similarity and low incidence (12/353 reported cases) (Table 2). The present review identified Type 1 as the most repeated pattern (32%), followed by patterns 2 (18%), 3 (9%), and 4 (13%). Type 5 is therefore the least recurrent pattern of transmigration with an incidence of 3% (Table 2). In our clinical retrospective analysis, Type 4 is the most common pattern of transmigration (5/9, Table 3). Undoubtedly, Mupparapu9 established a useful classification for grouping transmigrations together, which provides an appropriate point of reference, enables specialists to communicate more effectively, and unifies guidelines for treatment. However, we were unable to categorise 88/353 (25%) of transmigrations according to this classification (Table 2), because it does not apply to truly transmigrated canines,65 and although a conventional radiograph supplies valuable information it is 2-dimensional, with the inherent limitations.78 Three-dimensional diagnostic systems, such as cone-beam computed tomography (CT) and 3-dimensional magnetic resonance imaging, may complement conventional methods.36,80–87 The 3-dimensional methods offer more accurate information for diagnosing and treating transmigrated canines, particularly the resorption of roots of neighbouring teeth.36,80–82,84 This is an important issue, because resorption of roots of adjacent and anchoring teeth is thought to be an aetiological factor for the failure of orthodontic treatment in patients with impacted canines.88 The use of cone-beam CT may influence the outcome of treatment when compared with traditional panoramic radiographs for assessing impacted canines.88,89 Some classifications of impacted maxillary canines using this 3-dimensional technique have also been suggested,87–89 although to our knowledge none have been found for transmigrated mandibular canines. Numerous authors have reported transmigration as an asymptomatic clinical entity.11,65 However, the first published cases were associated with neurological changes,
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presumably induced by compression of the mental nerve by the mandibular canine transmigration.14,15 Clinical and radiographic findings associated with transmigration have included deviation from the midline, agenesis of the lateral incisors and lower premolars, and delayed eruption of canines or absence of the lower canines in the dental arch, or both.8,17,27,36,67 Early detection can improve the prognosis and treatment of transmigrated canines, as sometimes it is possible to preserve these teeth with orthodontic treatment and transplantation.56,64,70 It is also important to bear in mind that mandibular canines have an essential role in mastication and stable occlusion, and that transmigration may itself affect occlusion.70 This may be added to the previously mentioned complications, such as deviation from the midline or agenesis of adjacent teeth.74 The roots of the adjacent teeth may be resorbed, which in turn may limit their stability.80,84 Because of the malocclusion that a transmigrated canine can cause, orthodontic treatment is necessary either to rescue the tooth or to treat its consequences in the patient’s occlusion.70 Although the eruption of a transmigrated canine in the oral cavity is uncommon,2,6 our review found that 13 of the canines referenced had erupted (4%) (Table 2). Conversely, we found no erupted transmigrated canines in our study (Table 3). Forty-four (13%) of the transmigrated canines in our review presented with an associated condition (such as dentigerous cyst, or odontoma and dental impaction) (Table 2), which is thought to influence the dental malposition.34,76 We found an odontoma associated with mandibular canine transmigration in one of our nine cases (case 5, Table 3). A range of treatments may be available for a patient who presents with transmigrated canines, including extraction, self-transplantation, exposure and orthodontic alignment, and observation.1,11,51,64,77 Treatment depends partly on the radiographic position and maturity of the tooth, clinical signs, the patient’s wishes, and the overall plan of dental treatment.58 Nevertheless, in most cases treatment involves extraction of the impacted tooth.66 As stated by Camilleri and Scerri,54 extraction seems to be the most suitable treatment for migrated canines, rather than a heroic effort to put the tooth back in its original place. This holds true in cases where the crown of the canine has migrated past the contralateral incisor, or if the apex has migrated past the apex of the adjacent lateral incisor. In such cases it might be mechanically impossible to bring the canine into its correct position.54 Special attention should be paid when extracting a transmigrated mandibular canine, because the innervation emerges from the original side,14,15 so the anaesthesia of the nerve of the original side is indicated.4 If the mandibular incisors are correctly aligned within the arch and there is sufficient space to accommodate a canine, autotransplantation could be possible. However, the success of this technique is largely dependent on the development of the tooth, with greater success rates obtained in teeth the apices of which are incompletely formed with impacted roots.63 When the
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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diagnosis of a transmigrated tooth is made early, exposure and orthodontic alignment become the ideal solution. Consideration of the position and inclination of the tooth2,47 and close cooperation among the orthodontist, oral surgeon, and patient, are essential.63 Finally, it is also possible to leave the transmigrated canine in place, although the patient should have periodic clinical and radiographic surveillance.77 The patient should be advised of potential adverse complications, including the development of ankylosis, damage of adjacent anatomical structures, overlying resorption of a root, and dental malpositioning if the impacted tooth begins to erupt.8,9,41,59,77 In patients over 14 years of age, appreciable clinical changes are not expected, and observation is necessary if the patient refuses extraction.47,51 In summary, we have made a complete review of published cases of mandibular transmigrating cuspids since 1951, and described nine new (previously unreported) patients. Further studies are required to clarify the aetiology of mandibular canine transmigration. The diagnosis is based on radiographic and clinical studies. Extraction is the most common management. Periodic radiographic and clinical monitoring remain the standard when extraction is contraindicated, and early detection can improve the prognosis and treatment, and help to prevent complications.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patients’ permission The University Ethics Committee approved the study. Patients whose anonymous data are presented have consented to its use in publication for the benefit of scientific knowledge.
Acknowledgements We thank those patients who participated in the study.
References 1. Bluestone LI. The impacted mandibular bicuspid and canine: indications for removal and surgical considerations. Dent Items Interest 1951;73:341–55. 2. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3:117–21. 3. Broadway RT. A misplaced mandibular permanent canine. Br Dent J 1987;163:357–8. 4. Mitchell L. Displacement of a mandibular canine following fracture of the mandible. Br Dent J 1993;174:417–8. 5. Black SL, Zallen RD. An unusual case of tooth migration. Oral Surg Oral Med Oral Pathol 1973;36:607–8. 6. Barnett DP. An unusual transposition. Br J Orthod 1977;4:149.
7. Sofat JR. Maleruption of mandibular canine. A case report. J Indian Dent Assoc 1983;55:111–2. 8. Ando S, Aizaea K, Nakashima T, et al. Transmigration process of impacted mandibular cuspid. Journal of the Nihon University School of Dentistry 1964;6:66–71. 9. Mupparapu M. Patterns of intra-osseous transmigration and ectopic eruption of mandibular canines: review of literature and report of nine additional cases. Dentomaxillofac Radiol 2002;31:355–60. 10. Cowman SC, Wootton WR. Bilateral impaction of mandibular canines. N Z Dent J 1979;75:113–4. 11. Joshi MR, Shetye SB. Transmigration of mandibular canines: a review of the literature and report of two cases. Quintessence Int 1994;25:291–4. 12. Aydin U, Yilmaz HH. Transmigration of impacted canines. Dentomaxillofac Radiol 2003;32:198–200. 13. Thoma KH. Oral surgery. 2nd ed. St. Louis: Mosby; 1952 1075. 14. Caldwell JB. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1955;8: 484–7. 15. Bruszt P. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1958;11:89–90. 16. Stafne EC. Malposed mandibular canine. Oral Surg Oral Med Oral Pathol 1963;16:1330. 17. Kaufman AY, Buchner A, Gan R, et al. Transmigration of mandibular canine. Report of a case. Oral Surg Oral Med Oral Pathol 1967;23:648–50. 18. Fiedler LD, Alling CC. Malpositioned mandibular right canine: report of case. J Oral Surg 1968;26:405–7. 19. Pratt RJ. Migration of canine across the mandibular mid-line. Br Dent J 1969;126:463–4. 20. Pindborg JJ. Pathology of the dental hard tissues. Philadelphia: W. B. Saunders; 1970, 67–9. 21. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of nonerupted mandibular canines: report of cases. J Am Dent Assoc 1971;82:1395–7. 22. Heiman GR, Biven GM. Transmigrated or malposed mandibular cuspid. Oral Surg Oral Med Oral Pathol 1973;35:576. 23. Wechsler MH. An unusual cuspid impaction: report of case. J Can Dent Assoc (Tor) 1973;39:35–46. 24. Miranti R, Levbarg M. Extraction of a horizontally transmigrated impacted mandibular canine: report of case. J Am Dent Assoc 1974;88:607–10. 25. Greenberg SN, Orlian AI. Ectopic movement of an unerupted mandibular canine. J Am Dent Assoc 1976;93:125–8. 26. Abbott DM, Svirsky JA, Yarborough BH. Transposition of the permanent mandibular canine. Oral Surg Oral Med Oral Pathol 1980;49:97. 27. Hebda TW, Underwood AE. Transposed mandibular canine. Oral Surg Oral Med Oral Pathol 1980;50:197. 28. Zvolanek JW, Spotts TM, Kopperud WH. A transmigrated mandibular cuspid. Dent Radiogr Photogr 1981;54:38–9. 29. Joshi MR, Daruwala NR, Ahuja HC. Bilateral transmigration of mandibular canines. Br J Orthod 1982;9:57–8. 30. Kerr WJ. A migratory mandibular canine. Br J Orthod 1982;9:111–2. 31. Shapira Y, Mischler WA, Kuftinec MM. The displaced mandibular canine. ASDC J Dent Child 1982;49:362–4. 32. Barsley RE, Cade JE. Impacted mandibular cuspid and lateral incisor: report of an unusual case. J Oral Med 1984;39:165–8. 33. Nashashibi IA, Abu Shalhoub S. The transmigration of the lower mandibular canine. Odontostomatol Trop 1984;7:39–43. 34. O’Carroll MK. Transmigration of the mandibular right canine with development of odontoma in its place. Oral Surg Oral Med Oral Pathol 1984;57:349. 35. Vaskova J, Markova M. Extreme dystopia of canines or premolars in the mandible caused by intraosseous migration (in German). Zahn Mund Kieferheilkd Zentralbl 1984;72:673–8. 36. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14:547–9. 37. Dhooria HS, Sathawane RS, Mody RN, et al. Transmigration of mandibular canines. J Indian Dent Assoc 1986;58:348–51, 357.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
YBJOM-4751; No. of Pages 7
ARTICLE IN PRESS
RM. Díaz-Sánchez et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx 38. Gadgil RM. Impacted mandibular anterior teeth. Oral Surg Oral Med Oral Pathol 1986;61:106. 39. Jalili VP. X-ray oddities. Extreme medial and distal migration of mandibular canines. J Indian Dent Assoc 1986;58:9. 40. Mehta DS, Mehta MJ, Mrgesh SB, et al. Impactions of bilateral mandibular canines in criss-cross fashion. J Indian Dent Assoc 1986;58:549–51. 41. Gadalla GH. Mandibular incisor and canine ectopia. A case of two teeth erupted in the chin. Br Dent J 1987;163:236. 42. Ripari M, Maggiore C, Perfetti G, et al. Intraosseous migration of a retained mandibular canine (in Italian). Attual Dent 1988;4:42–5. 43. Shanmuhasuntharam P, Boon LC. Transmigration of permanent mandibular canines. Case report. Aust Dent J 1991;36:209–13. 44. Vichi M, Franchi L. The transmigration of the permanent lower canine (in Italian). Minerva Stomatol 1991;40:579–89. 45. Brezniak N, Ben-Yehuda A, Shapira Y. Unusual mandibular canine transposition: a case report. Am J Orthod Dentofacial Orthop 1993;104:91–4. 46. Kharbanda OP, Choudhury AR. Extreme transmigration of mandibular cuspid: report of two cases. J Clin Pediatr Dent 1994;18:307–8. 47. Wertz RA. Treatment of transmigrated mandibular canines. Am J Orthod Dentofacial Orthop 1994;106:419–27. 48. Kuftinec MM, Shapira Y, Nahlieli O. A case report. Bilateral transmigration of impacted mandibular canines. J Am Dent Assoc 1995;126:1022–4. 49. al-Waheidi EM. Transmigration of unerupted mandibular canines: a literature review and a report of five cases. Quintessence Int 1996;27:27–31. 50. Costello JP, Worth JC, Jones AG. Transmigration of permanent mandibular canines. Br Dent J 1996;181:212–3. 51. Alaejos-Algarra C, Berini-Aytes L, Gay-Escoda C. Transmigration of mandibular canines: report of six cases and review of the literature. Quintessence Int 1998;29:395–8. 52. Saéz-Cuesta U, Pe˜narrocha-Diago M, Sanchís-Bielsa JM, et al. Migration of mandibular canines (in Spanish). Revista del Ilustre Consejo General de Colegros de Odontologos y Estomatologos de Espana 1998;3:59–63. 53. Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective review of the literature. Angle Orthod 2001;71:12–22. 54. Camilleri S, Scerri E. Transmigration of mandibular canines–a review of the literature and a report of five cases. Angle Orthod 2003;73:753–62. 55. Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol 2004;33:164–9. 56. Auluck A, Nagpal A, Setty S, et al. Transmigration of impacted mandibular canines–report of 4 cases. J Can Dent Assoc 2006;72:249–52. 57. Camilleri S. Double transmigration and hyperdontia. Angle Orthod 2007;77:742–4. 58. González-Sánchez MA, Berini-Aytés L, Gay-Escoda C. Transmigrant impacted mandibular canines: a retrospective study of 15 cases. J Am Dent Assoc 2007;138:1450–5. 59. Mupparapu M, Auluck A, Suhaz S, et al. Patterns of intraosseous transmigration and ectopic eruption of bilaterally transmigrating mandibular canines: radiographic study and proposed classification. Quintessence Int 2007;38:821–8. 60. Sumer P, Sumer M, Ozden B, et al. Transmigration of mandibular canines: a report of six cases and a review of the literature. J Contemp Dent Pract 2007;8:104–10. 61. Buyukkurt MC, Aras MH, Caglaroglu M. Extraoral removal of a transmigrant mandibular canine associated with a dentigerous cyst. Quintessence Int 2008;39:767–70. 62. Aktan AM, Kara S, Akgünlü F, et al. The incidence of canine transmigration and tooth impaction in a Turkish subpopulation. Eur J Orthod 2010;32:575–81. 63. Celikoglu M, Kamak H, Oktay H. Investigation of transmigrated and impacted maxillary and mandibular canine teeth in an orthodontic patient population. J Oral Maxillofac Surg 2010;68:1001–6. 64. Trakyali G, Cildir SK, Sandalli N. Orthodontic treatment of a transmigrated mandibular canine: a case report. Aust Orthod J 2010;26:195–200. 65. Vuchkova J, Farah CS. Canine transmigration: comprehensive literature review and report of 4 new Australian cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e46–53.
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66. Gunashekhar M, Rohini M. Transmigration of mandibular canines: a rare case report and review of literature. J Dent Child (Chic) 2011;78:19–23. 67. Kara MI, Ay S, Aktan AM, et al. Analysis of different type of transmigrant mandibular teeth. Med Oral Patol Oral Cir Bucal 2011;16:e335–40. 68. Sharma G, Nagpal A. Transmigration of mandibular canine: report of four cases and review of literature. Case Rep Dent 2011;2011:381382. 69. Devadoss P, Neelakandan RS, Bhargava D, et al. Bilateral transmigration of mandibular canines: a rare occurrence. J Maxillofac Oral Surg 2012;11:495–7. 70. Holla A, Saify M, Parashar S. Transmigration of impacted mandibular canines and its association with malocclusion and morphology: An analysis of seven cases. Orthodontics (Chic) 2012;13:156–65. 71. Kontham U, Kontham R, Mistry J. Transmigration of mandibular canines in siblings: a case report. Quintessence Int 2012;43:45–9. 72. Kumar S, Urala AS, Kamath AT, et al. Unusual intraosseous transmigration of impacted tooth. Imaging Sci Dent 2012;42:47–54. 73. Mazinis E, Zafeiriadis A, Karathanasis A, et al. Transmigration of impacted canines: prevalence, management and implications on tooth structure and pulp vitality of adjacent teeth. Clin Oral Investig 2012;16:625–32. 74. Nagaveni NB. An unusual occurrence of multiple dental anomalies in a single nonsyndromic patient: a case report. Case Rep Dent 2012;2012:426091. 75. Bahl R, Singla J, Gupta M, et al. Abberantly placed impacted mandibular canine. Contemp Clin Dent 2013;4:217–9. 76. Madiraju GS, Rao KS, Singamaneni V. A rare case of transmigration of mandibular canine associated with an odontoma. BMJ Case Rep 2013:2013. 77. Umashree N, Kumar A, Nagaraj T. Transmigration of mandibular canines. Case Rep Dent 2013;2013:697671. 78. Gruszka K, Ró˙zyło TK, Ró˙zyło-Kalinowska I, et al. Transmigration of mandibular canine - case report. Pol J Radiol 2014;79:20–3. 79. Vaida L, Todor BI, Corega C, et al. A rare case of canine anomaly a possible algorithm for treating it. Rom J Morphol Embryol 2014;55: 1197–202. 80. Alqerban A, Jacobs R, Fieuws S, et al. Comparison of two cone-beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root resorption. Eur J Orthod 2011;33:93–102. 81. Rossini G, Cavallini C, Cassetta M, et al. Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature. Ann Stomatol (Roma) 2012;3:14–8. 82. Lai CS, Bornstein MM, Mock L, et al. Impacted maxillary canines and root resorptions of neighbouring teeth: a radiographic analysis using cone-beam computed tomography. Eur J Orthod 2013;35:529–38. 83. Pippi R, Kaitsas R. Mandibular canine transmigration: aethiopathogenetic aspects and six new reported cases. Oral Surg 2008;1:78–83. 84. Kumar S, Jayaswal P, Pentapati KC, et al. Investigation of the transmigrated canine in an orthodontic patient population. J Orthod 2012;39:89–94. 85. Kamiloglu B, Kelahmet U. Prevalence of impacted and transmigrated canine teeth in a Cypriote orthodontic population in the Northern Cyprus area. BMC Res Notes 2014;7:346. 86. Dalessandri D, Migliorati M, Rubiano R, et al. Reliability of a novel CBCT-based 3D classification system for maxillary canine impactions in orthodontics: the KPG index. Scientific World Journal 2013;2013:921234. 87. San Martín DE, English JD, Kau CH, et al. The KPG index–a novel 3D classification system for maxillary canine impactions. Tex Dent J 2012;129:265–74. 88. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod 2013;83:870–6. 89. Kau CH, Pan P, Gallerano RL, et al. A novel 3D classification system for canine impactions–the KPG index. Int J Med Robot 2009;5:291–6.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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Review
Transmigration of mandibular cuspids: review of published reports and description of nine new cases Rosa-María Díaz-Sánchez a , Raquel Castillo-de-Oyagüe a , María-Ángeles Serrera-Figallo a , Pilar Hita-Iglesias b , José-Luis Gutiérrez-Pérez a , Daniel Torres-Lagares a,∗ a b
Oral Surgery Department, Dental School, University of Seville Oral Surgery Department, University of Michigan
Accepted 10 January 2016
Abstract We have reviewed all documented cases of mandibular canine transmigration from1951 (when to our knowledge the first case was published) to 2015, and retrospectively evaluated nine further sequential cases of transmigrating mandibular canines in one hospital by analysing relevant data, including patients’ age and sex, presence of retained deciduous canines, radiographic changes, coexisting systemic diseases, and treatment. Transmigration of a mandibular canine is a rare anomaly of eruption, and extraction is the usual treatment. The nine new patients were aged from 16 -48 years, eight of the transmigrated canines were unilateral, and one patient had them bilaterally. They were all completely impacted. Four were retained primary teeth, and five exfoliated primary canines. Eight had no associated radiographic or clinical abnormalities, while one patient had an associated odontoma. Six mandibular canines were removed and three kept under observation. Early detection of transmigrated canines gives the opportunity to monitor their development, which may improve prognosis and treatment. © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Canine; Transmigration; Impaction; Tooth; Maleruption
Introduction Dental retention occurs when a permanent tooth remains unerupted for more than a year after the expected time of eruption. With the exception of third molars, retention is rare.1 The intraosseous migration of impacted teeth is an unusual dental anomaly, the origin2–5 and developmental process of which,6–10 are still obscure. The migration of a canine within the jaws is thought to start during early, mixed, dentition, so that most movement occurs before the root is formed.11–13 When part of an impacted tooth crosses the dental midline, its atypical ∗ Corresponding author at: Dental School – University of Seville, C/ Avicena s/n 41009, Sevilla (SPAIN). Tel.: +954481129; fax: +954481157. E-mail address: [email protected] (D. Torres-Lagares).
position is described as “transmigration.”9–12 Although this was first described in 1951,1 the definition and understanding were not standardised until much later. Various expressions such as “anomalous tooth,”2 “poorly positioned tooth.”3 “displaced tooth,”4 “unusual tooth,”5 “dislodged tooth”,6 and “poorly erupted tooth”7 have been applied to transmigrated teeth. In 1964, Ando et al.8 introduced the current term “transmigration,” and used “transmigrated tooth” to refer to the pattern of eruption. In 2002, Mupparapu9 proposed a classification for intraosseous transmigration and ectopic eruption of mandibular canines according to their migratory pattern and position in the jaw with respect to the dental midline, and described five types (Table 1). This categorisation has facilitated communication among clinicians. Although transmigration was thought initially to affect mandibular canines exclusively,9–11
http://dx.doi.org/10.1016/j.bjoms.2016.01.010 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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Table 1 Patterns of intraosseous transmigration and ectopic eruption of mandibular canines.9
Table 2 Documented cases of lower transmigrated canines from January 1951 to April 2015 (n=353 teeth in 319 patients).
Mupparapu pattern
Corresponding position of the mandibular canine
Variable
Type 1
Positioned mesioangularly across the midline with the jawbone, labial or lingual to the anterior teeth, and with the crown of the tooth crossing the midline. Horizontally impacted near the inferior border of the mandible below the apices of the incisors. Erupting either mesial or distal to the opposite canine. Horizontally impacted near the inferior border of the mandible below the apices of either the premolars or molars on the opposite side. Positioned vertically in the midline (with the long axis of the tooth crossing the midline) despite the state of eruption.
Type 2 Type 3 Type 4
Type 5
the theory was disproved in 2004 when Aydin and Yilmaz12 described a case of a transmigrating maxillary cuspid. Given that there is still uncertainty surrounding the procedure of dental migration, the purpose of this paper was to review the documented cases of mandibular canine transmigration since the first description in 1951 to date, and to report a series of nine new cases.
Site of transmigration (patients): Unilateral Bilateral Patients’ age range (years) Sex of patient: Male Female Not stated Condition of teeth: Erupted Not erupted Not known Patterns of teeth: 1 2 3 4 5 Not known Associated conditions of teeth: Yes No Not known
Number (%) 283 (89) 36 (11) 7-70 134 (42) 168 (53) 17 (5) 13 (4) 314 (89) 26 (7) 112 (32) 63 (18) 31 (9) 47 (13) 12 (3) 88 (25) 44 (13) 269 (76) 40 (11)
Patients, material, and methods We reviewed all reports of cases and series of mandibular canine transmigration published in the PubMed and MEDLINE electronic databases from January 1951 to April 2015. Papers available in English, French, German, Italian, and Spanish were considered. The search was made between March and April 2015. The key words / Medical Subject Headings (MeSH) used with different combinations were: mandibular canine transmigration, mandibular canine impaction, impacted tooth, dental migration, transmigrant canine, misplaced canine, maleruption, displaced canine, and eruption anomaly. We reviewed all the documented cases of mandibular canine transmigration in the languages specified. As this is a rare entity, we found no clinical trials on the subject. We were unable to do a meta-analysis because of the heterogeneity of the data. All cases of mandibular canine transmigration retrieved were therefore included in the revision and the following characteristics were assessed: age and sex of the patients, pattern of transmigration (Mupparapu classification),9 unilateral or bilateral location, presence of retained deciduous canines, eruption or lack of eruption of the transmigrated canines, pathological changes, associated anomalies, and treatment given. Retrospective clinical evaluation of nine new cases We retrospectively analysed the records of nine consecutive patients who presented with mandibular canine
transmigration to the Department of Oral Surgery of the University of Seville, Spain. This observational study was conducted in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki (as revised in Tokyo, 2004) and the Spanish Law 14/2007 of 3 July for Biomedical Research. All the participants were told about the purpose and process of the investigation. The assessment was made with the understanding and written consent of each subject and according to the abovementioned principles. Approval of the Ethics Committee of the University of Seville was obtained after their ethics board had independently reviewed the study protocol. Patients’ anonymity was preserved. All patients had preoperative panoramic radiographs taken, and the Mupparapu classification was applied in each case.9
Results The review of published reports found that 83 papers that described 319 patients with 353 transmigrated mandibular canines had been published since 1951 (Table 2).1–83 The radiographic and clinical data of our nine new cases are summarised in Table 3. Some radiographs are shown in Figs. 1 and 2. We found that mandibular canine transmigration was more common in women (6/9, Table 3) - a pattern that is in line with previous reports that indicated a female:male ratio between 2:1 and 3:1.49,55 The age range of the patients in the
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Table 3 Summaries of the nine new cases. Case No
Age (years)
Sex (M/F)
Diagnosis
Type of MCT
Position
Treatment
1
20
F
Lower left canine included
Left - 4
2
26
F
Lower right canine included
Right - 5
Extraction and primary lower left canine maintained Extraction
3
18
M
Left - 4
4
48
F
5
16
M
Upper left lateral incisor included Bilateral canines included Lower left canine included
Fully impacted, caudal to the apices of canine and premolars Fully impacted, vertical position, cusp crossing the midline Fully impacted Apical to the mandibular incisors Associated odontoma in the canine position
6
58
M
Lower left canine included
Left - 5
Apical to the mandibular incisors
7
21
F
Lower right canine included
Right - 4
8
47
F
Lower right canine included
Right - 2
Close proximity to the roots of the first lower molar Apical to the mandibular incisors
Periodic monitoring, refused extraction Extraction and simultaneous removal of odontoma Extraction. Loss of space because of the absence of the primary canine Extraction
9
22
Fe
Lower right canine included
Right - 4
Bilateral 2 Left - 4
Close proximity to the inferior left border of the mandible
Extraction
Periodic radiographic and clinical examination Periodic radiographic and clinical examination
MCT=mandibular canine transmigration.
Fig. 1. Cases 1 to 3. (A) Case 1: Lower left transmigrated canine. Note the deciduous tooth. (B) Case 2: Lower right impacted canine crossing the midline. We assumed the Mupparapu Type 5 pattern of transmigration.9 (C) Case 3: 18-year-old patient with lower left transmigrated canine.
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Fig. 2. Cases 7 to 9. (A) Case 7: Transmigration of the lower right impacted canine with the deciduous tooth still in the arch. (B) Case 8: Lower right impacted canine positioned horizontally. (C) Case 9: Lower right impacted canine positioned horizontally in a patient with cri du chat syndrome.
present study (16-58 years) (Table 3) was in agreement with that found in the review (7-70 years) (Table 2).1–85 While transmigration used to be a unilateral process involving a single mandibular canine,10,29,42,48,59,69 36 of the reported cases (11%) presented with bilateral transmigration (Table 2). Among our nine patients only one had bilateral disease (Table 3).
Discussion Mandibular canine transmigration is an atypical dental abnormality in which an unerupted mandibular canine migrates
and crosses the mandibular midline.69 This unusual condition is most often diagnosed by chance during a routine radiograph.78,79 The most common clinical signs are overretention of the deciduous canine and absence of the permanent canine in the dental arch after its physiological period of eruption.73,77 Mandibular canine transmigration is therefore thought to evolve at an early age, between 6 and 8 years, before the root has formed completely.24,53 Several hypotheses have been suggested to account for it: premature loss of deciduous teeth,24 osteodental discrepancy,51 displacement of the canine crypt,3 agenesis of the lower lateral incisors,44 endocrine pathology and heredity,24 local trauma,4 and oral disease.21,25,34,44,49 Some investigators
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have considered that the canine tooth germ anterior to the mandibular incisors may have been displaced toward the contralateral side with mandibular facial growth,15 while others have suggested that an abnormally strong eruptive force directed the canine to an aberrant position.43 The exact cause remains unknown. This rare condition preferentially affects the mandibular dental arch.36,59,62,67,68 Aydin et al.55 reported frequencies of transmigration for maxillary and mandibular canines of 0.1%, and 0.2%, respectively. The most common theory to account for its relative infrequency suggests that the shorter anatomical distance between the roots of the maxillary incisors and the floor of the nasal fossa, and the large roots of the maxillary incisors, are responsible.12,55 The higher cross-sectional area of the mandibular anterior region compared with that of the anterior maxilla might also be a reason for the higher incidence.55 In 2002, Mupparapu proposed a five-tier classification for mandibular canine transmigration (Table 1).9 We suggest that the Mupparapu Type 5 could be incorporated into Type 1 because of its similarity and low incidence (12/353 reported cases) (Table 2). The present review identified Type 1 as the most repeated pattern (32%), followed by patterns 2 (18%), 3 (9%), and 4 (13%). Type 5 is therefore the least recurrent pattern of transmigration with an incidence of 3% (Table 2). In our clinical retrospective analysis, Type 4 is the most common pattern of transmigration (5/9, Table 3). Undoubtedly, Mupparapu9 established a useful classification for grouping transmigrations together, which provides an appropriate point of reference, enables specialists to communicate more effectively, and unifies guidelines for treatment. However, we were unable to categorise 88/353 (25%) of transmigrations according to this classification (Table 2), because it does not apply to truly transmigrated canines,65 and although a conventional radiograph supplies valuable information it is 2-dimensional, with the inherent limitations.78 Three-dimensional diagnostic systems, such as cone-beam computed tomography (CT) and 3-dimensional magnetic resonance imaging, may complement conventional methods.36,80–87 The 3-dimensional methods offer more accurate information for diagnosing and treating transmigrated canines, particularly the resorption of roots of neighbouring teeth.36,80–82,84 This is an important issue, because resorption of roots of adjacent and anchoring teeth is thought to be an aetiological factor for the failure of orthodontic treatment in patients with impacted canines.88 The use of cone-beam CT may influence the outcome of treatment when compared with traditional panoramic radiographs for assessing impacted canines.88,89 Some classifications of impacted maxillary canines using this 3-dimensional technique have also been suggested,87–89 although to our knowledge none have been found for transmigrated mandibular canines. Numerous authors have reported transmigration as an asymptomatic clinical entity.11,65 However, the first published cases were associated with neurological changes,
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presumably induced by compression of the mental nerve by the mandibular canine transmigration.14,15 Clinical and radiographic findings associated with transmigration have included deviation from the midline, agenesis of the lateral incisors and lower premolars, and delayed eruption of canines or absence of the lower canines in the dental arch, or both.8,17,27,36,67 Early detection can improve the prognosis and treatment of transmigrated canines, as sometimes it is possible to preserve these teeth with orthodontic treatment and transplantation.56,64,70 It is also important to bear in mind that mandibular canines have an essential role in mastication and stable occlusion, and that transmigration may itself affect occlusion.70 This may be added to the previously mentioned complications, such as deviation from the midline or agenesis of adjacent teeth.74 The roots of the adjacent teeth may be resorbed, which in turn may limit their stability.80,84 Because of the malocclusion that a transmigrated canine can cause, orthodontic treatment is necessary either to rescue the tooth or to treat its consequences in the patient’s occlusion.70 Although the eruption of a transmigrated canine in the oral cavity is uncommon,2,6 our review found that 13 of the canines referenced had erupted (4%) (Table 2). Conversely, we found no erupted transmigrated canines in our study (Table 3). Forty-four (13%) of the transmigrated canines in our review presented with an associated condition (such as dentigerous cyst, or odontoma and dental impaction) (Table 2), which is thought to influence the dental malposition.34,76 We found an odontoma associated with mandibular canine transmigration in one of our nine cases (case 5, Table 3). A range of treatments may be available for a patient who presents with transmigrated canines, including extraction, self-transplantation, exposure and orthodontic alignment, and observation.1,11,51,64,77 Treatment depends partly on the radiographic position and maturity of the tooth, clinical signs, the patient’s wishes, and the overall plan of dental treatment.58 Nevertheless, in most cases treatment involves extraction of the impacted tooth.66 As stated by Camilleri and Scerri,54 extraction seems to be the most suitable treatment for migrated canines, rather than a heroic effort to put the tooth back in its original place. This holds true in cases where the crown of the canine has migrated past the contralateral incisor, or if the apex has migrated past the apex of the adjacent lateral incisor. In such cases it might be mechanically impossible to bring the canine into its correct position.54 Special attention should be paid when extracting a transmigrated mandibular canine, because the innervation emerges from the original side,14,15 so the anaesthesia of the nerve of the original side is indicated.4 If the mandibular incisors are correctly aligned within the arch and there is sufficient space to accommodate a canine, autotransplantation could be possible. However, the success of this technique is largely dependent on the development of the tooth, with greater success rates obtained in teeth the apices of which are incompletely formed with impacted roots.63 When the
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diagnosis of a transmigrated tooth is made early, exposure and orthodontic alignment become the ideal solution. Consideration of the position and inclination of the tooth2,47 and close cooperation among the orthodontist, oral surgeon, and patient, are essential.63 Finally, it is also possible to leave the transmigrated canine in place, although the patient should have periodic clinical and radiographic surveillance.77 The patient should be advised of potential adverse complications, including the development of ankylosis, damage of adjacent anatomical structures, overlying resorption of a root, and dental malpositioning if the impacted tooth begins to erupt.8,9,41,59,77 In patients over 14 years of age, appreciable clinical changes are not expected, and observation is necessary if the patient refuses extraction.47,51 In summary, we have made a complete review of published cases of mandibular transmigrating cuspids since 1951, and described nine new (previously unreported) patients. Further studies are required to clarify the aetiology of mandibular canine transmigration. The diagnosis is based on radiographic and clinical studies. Extraction is the most common management. Periodic radiographic and clinical monitoring remain the standard when extraction is contraindicated, and early detection can improve the prognosis and treatment, and help to prevent complications.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patients’ permission The University Ethics Committee approved the study. Patients whose anonymous data are presented have consented to its use in publication for the benefit of scientific knowledge.
Acknowledgements We thank those patients who participated in the study.
References 1. Bluestone LI. The impacted mandibular bicuspid and canine: indications for removal and surgical considerations. Dent Items Interest 1951;73:341–55. 2. Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3:117–21. 3. Broadway RT. A misplaced mandibular permanent canine. Br Dent J 1987;163:357–8. 4. Mitchell L. Displacement of a mandibular canine following fracture of the mandible. Br Dent J 1993;174:417–8. 5. Black SL, Zallen RD. An unusual case of tooth migration. Oral Surg Oral Med Oral Pathol 1973;36:607–8. 6. Barnett DP. An unusual transposition. Br J Orthod 1977;4:149.
7. Sofat JR. Maleruption of mandibular canine. A case report. J Indian Dent Assoc 1983;55:111–2. 8. Ando S, Aizaea K, Nakashima T, et al. Transmigration process of impacted mandibular cuspid. Journal of the Nihon University School of Dentistry 1964;6:66–71. 9. Mupparapu M. Patterns of intra-osseous transmigration and ectopic eruption of mandibular canines: review of literature and report of nine additional cases. Dentomaxillofac Radiol 2002;31:355–60. 10. Cowman SC, Wootton WR. Bilateral impaction of mandibular canines. N Z Dent J 1979;75:113–4. 11. Joshi MR, Shetye SB. Transmigration of mandibular canines: a review of the literature and report of two cases. Quintessence Int 1994;25:291–4. 12. Aydin U, Yilmaz HH. Transmigration of impacted canines. Dentomaxillofac Radiol 2003;32:198–200. 13. Thoma KH. Oral surgery. 2nd ed. St. Louis: Mosby; 1952 1075. 14. Caldwell JB. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1955;8: 484–7. 15. Bruszt P. Neurological anomaly associated with extreme malposition of a mandibular canine. Oral Surg Oral Med Oral Pathol 1958;11:89–90. 16. Stafne EC. Malposed mandibular canine. Oral Surg Oral Med Oral Pathol 1963;16:1330. 17. Kaufman AY, Buchner A, Gan R, et al. Transmigration of mandibular canine. Report of a case. Oral Surg Oral Med Oral Pathol 1967;23:648–50. 18. Fiedler LD, Alling CC. Malpositioned mandibular right canine: report of case. J Oral Surg 1968;26:405–7. 19. Pratt RJ. Migration of canine across the mandibular mid-line. Br Dent J 1969;126:463–4. 20. Pindborg JJ. Pathology of the dental hard tissues. Philadelphia: W. B. Saunders; 1970, 67–9. 21. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of nonerupted mandibular canines: report of cases. J Am Dent Assoc 1971;82:1395–7. 22. Heiman GR, Biven GM. Transmigrated or malposed mandibular cuspid. Oral Surg Oral Med Oral Pathol 1973;35:576. 23. Wechsler MH. An unusual cuspid impaction: report of case. J Can Dent Assoc (Tor) 1973;39:35–46. 24. Miranti R, Levbarg M. Extraction of a horizontally transmigrated impacted mandibular canine: report of case. J Am Dent Assoc 1974;88:607–10. 25. Greenberg SN, Orlian AI. Ectopic movement of an unerupted mandibular canine. J Am Dent Assoc 1976;93:125–8. 26. Abbott DM, Svirsky JA, Yarborough BH. Transposition of the permanent mandibular canine. Oral Surg Oral Med Oral Pathol 1980;49:97. 27. Hebda TW, Underwood AE. Transposed mandibular canine. Oral Surg Oral Med Oral Pathol 1980;50:197. 28. Zvolanek JW, Spotts TM, Kopperud WH. A transmigrated mandibular cuspid. Dent Radiogr Photogr 1981;54:38–9. 29. Joshi MR, Daruwala NR, Ahuja HC. Bilateral transmigration of mandibular canines. Br J Orthod 1982;9:57–8. 30. Kerr WJ. A migratory mandibular canine. Br J Orthod 1982;9:111–2. 31. Shapira Y, Mischler WA, Kuftinec MM. The displaced mandibular canine. ASDC J Dent Child 1982;49:362–4. 32. Barsley RE, Cade JE. Impacted mandibular cuspid and lateral incisor: report of an unusual case. J Oral Med 1984;39:165–8. 33. Nashashibi IA, Abu Shalhoub S. The transmigration of the lower mandibular canine. Odontostomatol Trop 1984;7:39–43. 34. O’Carroll MK. Transmigration of the mandibular right canine with development of odontoma in its place. Oral Surg Oral Med Oral Pathol 1984;57:349. 35. Vaskova J, Markova M. Extreme dystopia of canines or premolars in the mandible caused by intraosseous migration (in German). Zahn Mund Kieferheilkd Zentralbl 1984;72:673–8. 36. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14:547–9. 37. Dhooria HS, Sathawane RS, Mody RN, et al. Transmigration of mandibular canines. J Indian Dent Assoc 1986;58:348–51, 357.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010
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RM. Díaz-Sánchez et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx 38. Gadgil RM. Impacted mandibular anterior teeth. Oral Surg Oral Med Oral Pathol 1986;61:106. 39. Jalili VP. X-ray oddities. Extreme medial and distal migration of mandibular canines. J Indian Dent Assoc 1986;58:9. 40. Mehta DS, Mehta MJ, Mrgesh SB, et al. Impactions of bilateral mandibular canines in criss-cross fashion. J Indian Dent Assoc 1986;58:549–51. 41. Gadalla GH. Mandibular incisor and canine ectopia. A case of two teeth erupted in the chin. Br Dent J 1987;163:236. 42. Ripari M, Maggiore C, Perfetti G, et al. Intraosseous migration of a retained mandibular canine (in Italian). Attual Dent 1988;4:42–5. 43. Shanmuhasuntharam P, Boon LC. Transmigration of permanent mandibular canines. Case report. Aust Dent J 1991;36:209–13. 44. Vichi M, Franchi L. The transmigration of the permanent lower canine (in Italian). Minerva Stomatol 1991;40:579–89. 45. Brezniak N, Ben-Yehuda A, Shapira Y. Unusual mandibular canine transposition: a case report. Am J Orthod Dentofacial Orthop 1993;104:91–4. 46. Kharbanda OP, Choudhury AR. Extreme transmigration of mandibular cuspid: report of two cases. J Clin Pediatr Dent 1994;18:307–8. 47. Wertz RA. Treatment of transmigrated mandibular canines. Am J Orthod Dentofacial Orthop 1994;106:419–27. 48. Kuftinec MM, Shapira Y, Nahlieli O. A case report. Bilateral transmigration of impacted mandibular canines. J Am Dent Assoc 1995;126:1022–4. 49. al-Waheidi EM. Transmigration of unerupted mandibular canines: a literature review and a report of five cases. Quintessence Int 1996;27:27–31. 50. Costello JP, Worth JC, Jones AG. Transmigration of permanent mandibular canines. Br Dent J 1996;181:212–3. 51. Alaejos-Algarra C, Berini-Aytes L, Gay-Escoda C. Transmigration of mandibular canines: report of six cases and review of the literature. Quintessence Int 1998;29:395–8. 52. Saéz-Cuesta U, Pe˜narrocha-Diago M, Sanchís-Bielsa JM, et al. Migration of mandibular canines (in Spanish). Revista del Ilustre Consejo General de Colegros de Odontologos y Estomatologos de Espana 1998;3:59–63. 53. Joshi MR. Transmigrant mandibular canines: a record of 28 cases and a retrospective review of the literature. Angle Orthod 2001;71:12–22. 54. Camilleri S, Scerri E. Transmigration of mandibular canines–a review of the literature and a report of five cases. Angle Orthod 2003;73:753–62. 55. Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol 2004;33:164–9. 56. Auluck A, Nagpal A, Setty S, et al. Transmigration of impacted mandibular canines–report of 4 cases. J Can Dent Assoc 2006;72:249–52. 57. Camilleri S. Double transmigration and hyperdontia. Angle Orthod 2007;77:742–4. 58. González-Sánchez MA, Berini-Aytés L, Gay-Escoda C. Transmigrant impacted mandibular canines: a retrospective study of 15 cases. J Am Dent Assoc 2007;138:1450–5. 59. Mupparapu M, Auluck A, Suhaz S, et al. Patterns of intraosseous transmigration and ectopic eruption of bilaterally transmigrating mandibular canines: radiographic study and proposed classification. Quintessence Int 2007;38:821–8. 60. Sumer P, Sumer M, Ozden B, et al. Transmigration of mandibular canines: a report of six cases and a review of the literature. J Contemp Dent Pract 2007;8:104–10. 61. Buyukkurt MC, Aras MH, Caglaroglu M. Extraoral removal of a transmigrant mandibular canine associated with a dentigerous cyst. Quintessence Int 2008;39:767–70. 62. Aktan AM, Kara S, Akgünlü F, et al. The incidence of canine transmigration and tooth impaction in a Turkish subpopulation. Eur J Orthod 2010;32:575–81. 63. Celikoglu M, Kamak H, Oktay H. Investigation of transmigrated and impacted maxillary and mandibular canine teeth in an orthodontic patient population. J Oral Maxillofac Surg 2010;68:1001–6. 64. Trakyali G, Cildir SK, Sandalli N. Orthodontic treatment of a transmigrated mandibular canine: a case report. Aust Orthod J 2010;26:195–200. 65. Vuchkova J, Farah CS. Canine transmigration: comprehensive literature review and report of 4 new Australian cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e46–53.
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66. Gunashekhar M, Rohini M. Transmigration of mandibular canines: a rare case report and review of literature. J Dent Child (Chic) 2011;78:19–23. 67. Kara MI, Ay S, Aktan AM, et al. Analysis of different type of transmigrant mandibular teeth. Med Oral Patol Oral Cir Bucal 2011;16:e335–40. 68. Sharma G, Nagpal A. Transmigration of mandibular canine: report of four cases and review of literature. Case Rep Dent 2011;2011:381382. 69. Devadoss P, Neelakandan RS, Bhargava D, et al. Bilateral transmigration of mandibular canines: a rare occurrence. J Maxillofac Oral Surg 2012;11:495–7. 70. Holla A, Saify M, Parashar S. Transmigration of impacted mandibular canines and its association with malocclusion and morphology: An analysis of seven cases. Orthodontics (Chic) 2012;13:156–65. 71. Kontham U, Kontham R, Mistry J. Transmigration of mandibular canines in siblings: a case report. Quintessence Int 2012;43:45–9. 72. Kumar S, Urala AS, Kamath AT, et al. Unusual intraosseous transmigration of impacted tooth. Imaging Sci Dent 2012;42:47–54. 73. Mazinis E, Zafeiriadis A, Karathanasis A, et al. Transmigration of impacted canines: prevalence, management and implications on tooth structure and pulp vitality of adjacent teeth. Clin Oral Investig 2012;16:625–32. 74. Nagaveni NB. An unusual occurrence of multiple dental anomalies in a single nonsyndromic patient: a case report. Case Rep Dent 2012;2012:426091. 75. Bahl R, Singla J, Gupta M, et al. Abberantly placed impacted mandibular canine. Contemp Clin Dent 2013;4:217–9. 76. Madiraju GS, Rao KS, Singamaneni V. A rare case of transmigration of mandibular canine associated with an odontoma. BMJ Case Rep 2013:2013. 77. Umashree N, Kumar A, Nagaraj T. Transmigration of mandibular canines. Case Rep Dent 2013;2013:697671. 78. Gruszka K, Ró˙zyło TK, Ró˙zyło-Kalinowska I, et al. Transmigration of mandibular canine - case report. Pol J Radiol 2014;79:20–3. 79. Vaida L, Todor BI, Corega C, et al. A rare case of canine anomaly a possible algorithm for treating it. Rom J Morphol Embryol 2014;55: 1197–202. 80. Alqerban A, Jacobs R, Fieuws S, et al. Comparison of two cone-beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root resorption. Eur J Orthod 2011;33:93–102. 81. Rossini G, Cavallini C, Cassetta M, et al. Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature. Ann Stomatol (Roma) 2012;3:14–8. 82. Lai CS, Bornstein MM, Mock L, et al. Impacted maxillary canines and root resorptions of neighbouring teeth: a radiographic analysis using cone-beam computed tomography. Eur J Orthod 2013;35:529–38. 83. Pippi R, Kaitsas R. Mandibular canine transmigration: aethiopathogenetic aspects and six new reported cases. Oral Surg 2008;1:78–83. 84. Kumar S, Jayaswal P, Pentapati KC, et al. Investigation of the transmigrated canine in an orthodontic patient population. J Orthod 2012;39:89–94. 85. Kamiloglu B, Kelahmet U. Prevalence of impacted and transmigrated canine teeth in a Cypriote orthodontic population in the Northern Cyprus area. BMC Res Notes 2014;7:346. 86. Dalessandri D, Migliorati M, Rubiano R, et al. Reliability of a novel CBCT-based 3D classification system for maxillary canine impactions in orthodontics: the KPG index. Scientific World Journal 2013;2013:921234. 87. San Martín DE, English JD, Kau CH, et al. The KPG index–a novel 3D classification system for maxillary canine impactions. Tex Dent J 2012;129:265–74. 88. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod 2013;83:870–6. 89. Kau CH, Pan P, Gallerano RL, et al. A novel 3D classification system for canine impactions–the KPG index. Int J Med Robot 2009;5:291–6.
Please cite this article in press as: Díaz-Sánchez RM, et al. Transmigration of mandibular cuspids: review of published reports and description of nine new cases. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2016.01.010