Maxillary canines are the second most common teeth to become impacted after the third molars. The incidence in the general population has been described as anywhere from 1% to 3%, appearing in females 2-3 times more frequently than in males. Approximately two-thirds of impacted canines are displaced palatally.
Management of impacted maxillary canines poses unique challenges to orthodontists. The potential for resorption of adjacent roots, the possibility of ankylosis, the need for surgical exposure, increased treatment time, and the possible need for periodontal surgery or endodontic treatment after the tooth’s eruption, all increase the risk of adverse effects. Management of these risks is essential for a successful treatment outcome.
Case report
A female aged 10 years 5 months was referred by her general dentist for orthodontic treatment. Initial records consisted of intraoral and facial photographs, a lateral cephalogram, and a panoramic radiograph ( Fig 1 ). The doctor’s diagnosis consisted of mild maxillary constriction, a Class II dental malocclusion, and blocked out maxillary and mandibular canines in the mixed dentition.
Pretreatment panoramic radiograph.
The treatment plan consisted of 2 phases. The first phase began with a fixed rapid palatal expander and bonded appliances on all first molars and incisors. The second phase involved full fixed appliances with the surgical exposure of the maxillary canines. Total treatment time for the 2 phases was estimated at 36 months. A pretreatment conference was held with the parents, and informed consent was obtained.
Eight months into treatment, the original orthodontist retired and sold his practice to a group of 3 orthodontists. Including the original doctor, all 4 orthodontists treated the patient. After 22 months, a progress panoramic radiograph was taken ( Fig 2 ).
Progress radiograph, 22 months into treatment.
Root resorption was evident on the maxillary incisors, but there was nothing mentioned about it in the patient’s treatment record, nor were the parents informed about the resorption. The patient was referred to an oral surgeon for the exposure and placement of gold chain attachments on the maxillary canines. The oral surgeon also did not inform the parents about the root resorption. Fixed appliances were placed on the remaining erupted teeth.
After an additional 8 months of treatment, the gold chain detached from the maxillary right canine. A second progress panoramic radiograph was taken ( Fig 3 ).
Progress radiograph, 30 months into treatment.
Severe root resorption was now evident on all 4 maxillary incisors. The parents were told that the maxillary right canine was ankylosed and required extraction. Again, nothing was said to them about the root resorption, nor was it mentioned in the patient’s treatment record.
Now 30 months into a 36-month treatment plan and with no visible sign of the maxillary canines, the parents sought a second opinion, in which they were told their daughter could expect to lose her 4 maxillary incisors. At this point, the parents sought legal advice, which resulted in filing a lawsuit against the original orthodontist, the new owners of the practice, and their corporation, claiming orthodontic malpractice.
