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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 49  |  Issue : 1  |  Page : 42-45

Varied clinico-radiological presentations of transmigrated canines


1 MDS, Department of Oral Medicine and radiology, Faculty of Dental Sciences, SGT University, Budhera, Haryana, India
2 MDS, KLE Institute of Dental Sciences, Belgaum, Karnataka, India
3 MDS, Geeta Dental Hospital, Mumbai, Maharashtra, India

Date of Submission11-Oct-2014
Date of Acceptance24-Mar-2015
Date of Web Publication12-Jun-2015

Correspondence Address:
Ishita Gupta
32/B, DDA MIG Flats, Pocket 2, Sector 7, Dwarka, New Delhi - 110 075
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-5742.158633

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  Abstract 

Canine is one of the most commonly impacted teeth in the dental arch. An unerupted permanent canine crossing the midline is called transmigration and is an unusual event. We report nine cases of impacted canine transmigration. Maxillary canine transmigration, bilateral transmigration, and transmigration associated with odontoma are rare presentations. This article discusses the varied clinico-radiologic presentations, etiology, and treatment options of transmigration. It also emphasizes the importance of panoramic radiographs for evaluation of over-retained deciduous canines or missing permanent canines.

Keywords: Bilateral transmigration, canine impaction, tooth migration, transmigration


How to cite this article:
Gupta I, Chaudhry A, Keluskar V, Mathur H. Varied clinico-radiological presentations of transmigrated canines . J Indian Orthod Soc 2015;49:42-5

How to cite this URL:
Gupta I, Chaudhry A, Keluskar V, Mathur H. Varied clinico-radiological presentations of transmigrated canines . J Indian Orthod Soc [serial online] 2015 [cited 2017 May 24];49:42-5. Available from: http://www.jios.in/text.asp?2015/49/1/42/158633


  Introduction Top


Impaction refers to the failure of a tooth to appear into the dental arch. An impacted tooth may migrate in the dental arch in the direction of crown under the influence of eruptive force before completion of root formation. [1] If the tooth migrates and crosses the midline, it is called "transmigration." [2] Maxillary canines are commonly impacted but transmigration is usually observed with mandibular canines. Transmigrated teeth are typically asymptomatic diagnosed on routine panoramic radiography taken for evaluation of missing permanent canines or retained deciduous canines. However, if symptomatic they can cause pressure resorption of roots or tilting of adjacent teeth and even pain and neuralgic symptoms. [3] Therefore, their timely diagnosis is utmost important. We discuss nine cases of impacted canine transmigration showing varied clinical and radiologic features.


  Case Report Top


The clinical and radiographic features of the cases are shown in [Table 1] [Figure 1] [Figure 2] [Figure 3] [Figure 4] [Figure 5] [Figure 6] [Figure 7] [Figure 8] [Figure 9].
Figure 1: Panoramic radiograph showing bilateral transmigrated canines horizontally impacted near the inferior border of the mandible below the apices of the mandibular incisor teeth with right canine showing follicular enlargement

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Figure 2: Panoramic radiograph showing bilaterally transmigrated canines below the apices of the mandibular incisor teeth and left canine penetrating the inferior cortical border of mandible

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Figure 3: Panoramic radiograph showing bilaterally "kissing" canines in the midline

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Figure 4: Panoramic radiograph revealing mesio-angularly impacted left mandibular canine crossing the midline and dentigerous cyst associated with odontoma

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Figure 5: Panoramic radiograph showing mesio-angularly impacted right mandibular canine crossing the midline in association with dentigerous cyst

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Figure 6: Panoramic radiograph showing transmigrated right mandibular canine horizontally impacted near the inferior border of the mandible below the apices of the mandibular incisor teeth

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Figure 7: Panoramic image showing mesio-angularly impacted left maxillary canine abutting the intermaxillary suture

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Figure 8: Panoramic image showing mesio-angularly impacted left maxillary canine abutting the midline

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Figure 9: Panoramic image showing mesio-angularly impacted left maxillary canine just crossing the midline in completely edentulous jaws

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Table 1: Features of transmigrated impacted canines


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  Discussion Top


Mandibular canine impaction is uncommon as compared to the maxillary canine. However, transmigration is more commonly exhibited by mandibular canines. [3],[4] This can be attributed to the conical crown, the long root of canine and greater cross-sectional area of the symphysis. [5] Transmigration is usually considered a rare phenomenon with a prevalence of only 0.31% [6] and generally unilateral transmigration is seen. Bilateral transmigration is very rare with an incidence of only 9% [3] and we report three such cases with different presentations. Case 1 showed the antiparallel orientation of both the canines in the midline at the inferior border of the mandible. Case 2 showed both the canines positioned one above another at the inferior border of mandible, but the left canine showed a reverse oblique angulation of about 110° piercing the inferior cortical border of the mandible. Only one such case of unilateral mandibular canine transmigration has been reported in literature till now. [7] Case 3 showed mesioangularly impacted transmigrated canines "kissing" in the midline. Case 3 also shows horizontally placed right central incisor crossing the midline. However, it cannot be considered as transmigration as it has occurred after tooth eruption due to pathologic migration. The unilateral transmigrated mandibular canines reported here also shows variable presentations. Case 4 shows mesioangularly impacted left mandibular canine crossing the midline along with an odontome associated with the dentigerous cyst. Case 5 showed a dentigerous cyst in association with the mesioangularly impacted right mandibular canine crossing the midline. Case 6 showed horizontally placed right mandibular canine at the inferior border of the mandible. These presentations come under the category I and II of Mupparappu's classification [4] which are the most commonly encountered types. However, bilateral transmigration does not fit properly into any of the five types proposed. Hence, a separate type 4 has been proposed by Qaradaghi, [8] which is defined as "the parallel migration of both canines at the same rate to the contralateral site." It is a combination of type 1 and type 2. According to this, Case 1, 2, 3 comes under the category VI.

Recently, transmigration has been reported in maxillary canines, lateral incisors, and premolars. [1],[2],[9] Maxillary canine transmigration is very rare due to the reduced distance between the incisors roots and floor of nasal cavity and restriction posed by the strong midpalatal suture. [10] We have discussed three cases of unilateral maxillary canine transmigration. Due to the paucity of the reported maxillary canine transmigration in literature, no classification has been proposed till now.

Transmigration is found more frequently in females and on the left side. [4] In the nine cases presented here, five were found in males and out of six unilateral transmigrations four were from the left. Multiple etiologies have been proposed. Abnormal displacement of tooth bud during development is the most accepted one. [3],[11] Pippi and Kaitsas [12] proposed that the simultaneous presence of strong eruptive force during root formation and enlarged follicular space creates an osteolytic area which offers less resistance to tooth movement. Other contributing factors include premature loss or over-retained deciduous teeth, crowding, spacing, unfavorable arch length, trauma, tumor, odontomas, and cyst, [9],[11] all of which alters the guide for the path of eruption. In our series, Case 1 was associated with follicular enlargement and arch length discrepancy, Case 2 showed retained deciduous teeth and spacing, and Case 3 showed missing mandibular central incisors and increased spacing. However, the simultaneous rate and distance covered by both the canines in these cases points toward an unknown control mechanism. In Case 4 it is difficult to predict whether transmigration occurred prior to cyst formation around odontome or due to the pressure exerted by the developing cyst. May be this hypothesis explains its occurrence in the 7 th decade of life. Case 5 showed transmigration under the influence of developing dentigerous cyst around developing 43 along with retained 85. Case 7 and 8 showed arch length related factors and Case 9 is the most peculiar one, seen in completely edentulous jaws as post permanent dentition. It might have been a mesioangularly impacted canine that transmigrated due to the space created by the extractions. Except, Case 1 and 5, transmigration was seen in the elderly age group, where the root formation of canines has been completed long back but still movement was seen due to continuous apposition of cementum and bone remodeling.

It has been proposed that transmigration should include only those cases in which more than half of the tooth had crossed the midline. [11] However, the tendency to cross the midline is more important as the distance migrated can vary with the stage of diagnosis. [3] The same concept was used in Case 7 and 8 where the tooth was just at the midline and had a strong tendency to migrate. It has been observed that the impacted canines that lie at an axial angulation of 30-95° have a tendency to cross the midline and when the angle exceeds 50°; transmigration is inevitable. [13] Cases 7, 8 and 9 showed angulation between 70° and 80° suggesting a strong horizontal component of the eruptive force which can overcome the mid palatal suture barrier.

Transmigrated canines are usually asymptomatic and discovered on routine panoramic radiograph taken for orthodontic purposes. They can sometimes be associated with pain and discomfort, swelling or paresthesia due to impingement of mandibular canal. [3],[5] All the cases were asymptomatic except Case 4 that presented with pain due to the infected cyst. Transmigration is frequently associated with developmental anomalies like over-retained deciduous teeth, microdontia, ectopic eruption, hypodontia or supernumerary teeth. [5],[11] Few of the these were also observed in our cases [Table 1].

Management of transmigration mainly involves surgical extraction. [14] In asymptomatic patients with no pathological changes, surgical extraction can be deferred, and the patient can be put on periodic follow-up. Accordingly Cases 3, 6,7 and 8 were advised regular follow-up. However, if any progressive mesial tilting and migration or cystic changes are noted then surgical extraction should be planned. During surgical extraction, it is important to anesthetize the nerve on the contralateral side as the transmigrated canine maintains the nerve connection to the originating side. [5] Case 1 was advised surgical extraction but did not come for follow-up. Case 2 was also advised extraction because of the reverse oblique angulation which if left untreated could lead to perforation of the inferior border of the mandible. In Case 4 and 5, the cyst was enucleated along with the extraction of odontoma and canine. Case 9 was advised extraction to facilitate complete prosthetic rehabilitation. In case of orthodontic treatment, erupted transmigrated canine should be extracted instead of the usual premolars to prevent excessive treatment time. Surgical exposure with orthodontic realignment can be attempted for the labially placed canine in non-extraction cases when the crown has not migrated past the adjacent lateral incisor. [14] Surgical repositioning and transplantation when enough space is available are other treatment options. If the canine has ectopically erupted into the oral cavity, then orthodontic realignment and recontouring of a crown can be attempted. [9],[14]


  Conclusion Top


Transmigration was supposed to be a rare phenomenon in olden days before the advent of panoramic radiography. The prescription of orthopantomogram as a routine radiograph and for evaluation of over-retained deciduous canines or missing permanent canines has led to increased detection of cases of transmigration. We have added nine more cases to the literature showing diverse clinical and radiographic presentations. Since, canines are the cornerstones of the dental arch, early detection of this phenomenon will ensure better treatment options and might help in the preservation of canines, which are necessary to maintain both the esthetics and function. Unlike the mandibular canines, the classification system is required for maxillary canines and other teeth that will help in better understanding of this dental anomaly.

 
  References Top

1.
Aktan AM, Kara S, Akgünlü F, Malkoç S. The incidence of canine transmigration and tooth impaction in a Turkish subpopulation. Eur J Orthod 2010;32:575-81.  Back to cited text no. 1
    
2.
Aydin U, Yilmaz HH, Yildirim D. Incidence of canine impaction and transmigration in a patient population. Dentomaxillofac Radiol 2004;33:164-9.  Back to cited text no. 2
    
3.
Joshi MR. Transmigrant mandibular canines: A record of 28 cases and a retrospective review of the literature. Angle Orthod 2001;71:12-22.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Auluck A, Nagpal A, Setty S, Pai KM, Sunny J. Transmigration of impacted mandibular canines - A report of four cases. J Can Dent Assoc 2006;72:249-52.   Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
Umashree N, Kumar A, Nagaraj T. Transmigration of mandibular canines. Case Rep Dent 2013;2013:697671.  Back to cited text no. 7
    
8.
Qaradaghi IF. Transmigration of impacted canines: A report of four cases and a review of the literature. Hell Orthod Rev 2009;12:35-42.  Back to cited text no. 8
    
9.
Kumar S, Urala AS, Kamath AT, Jayaswal P, Valiathan A. Unusual intraosseous transmigration of impacted tooth. Imaging Sci Dent 2012;42:47-54.  Back to cited text no. 9
    
10.
Ryan FS, Batra P, Witherow H, Calvert M. Transmigration of a maxillary canine. A case report. Prim Dent Care 2005;12:70-2.  Back to cited text no. 10
    
11.
Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg 1985;14:547-9.  Back to cited text no. 11
    
12.
Pippi R, Kaitsas R. Mandibular canine transmigration: Aetiopathogenetic aspects and six new reported cases. Oral Surg 2008;1:78-83.  Back to cited text no. 12
    
13.
Howard RD. The anomalous mandibular canine. Br J Orthod 1976;3:117-21.  Back to cited text no. 13
    
14.
Wertz RA. Treatment of transmigrated mandibular canines. Am J Orthod Dentofacial Orthop 1994;106:419-27.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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