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CASE REPORT

PATTERN OF BILATERAL TRANSMIGRATION OF IMPACTED MANDIBULAR CANINES: A RADIOGRAPHIC STUDY OF 3 CASES

Achint Garg1, Suraj Agarwal2, Shweta Agarwal3, Samta Mittal4, Parul Singh5


HOW TO CITE THIS ARTICLE:

Achint Garg, Suraj Agarwal, Shweta Agarwal, Samta Mittal, Parul Singh. ”Pattern of Bilateral Transmigration of Impacted Mandibular Canines: A Radiographic Study of 3 Cases”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 7, February 16, 2015; Page: 921-928.


INTRODUCTION: Migration of a tooth across the midline is called TRANSMIGRATION which is a rare anomaly. Nodine (1943)1 & Thoma (1952)2 observed this condition in pre-historic skulls & living patients respectively. Ando et al (1964)3 were the first to use the term ‘‘transmigration”. Tarsitano (1971)4 et al defined transmigration as the phenomenon of an unerupted tooth crossing the midline. Javid (1985),5 expanded the definition to include, more than half the tooth which had passed through the midline. Joshi (2001)6 felt that the tendency of a canine to cross the barrier of the midline suture is more important consideration than the distance travelled.

Transmigration is mainly associated with impacted teeth. Though all permanent teeth may be impacted, yet mandibular and maxillary third molars, maxillary canines, maxillary and mandibular premolars, mandibular canines and maxillary central incisors are the teeth most frequently involved in the mentioned order. Maxillary canine impaction is a well-known dental anomaly and its incidence is in the range 0.8–2.8%.7 Mandibular canine impaction is less frequent. It is observed that transmigration involves almost exclusively mandibular and maxillary canines. Literature reports transmigration of mandibular canines are much higher than those of maxillary canines.8 Of the reported cases of transmigration, the bilateral type of transmigration is even rare,very few cases have been reported so far.9 Mupparapu has proposed a classification for both unilaterally and bilaterally transmigrating mandibular canines.(Figure 1 & 2) Documented cases of bilateral canine transmigration and the patterns of transmigration were studied in depth for this report, and 3 new cases are added.





Fig. 1: Diagrammatic representation of the five distinct patterns of unilateral transmigration of mandibular canines by Mupparappu





Fig. 2: Diagrammatic representation of transmigrating mandibular canines axially inclined at 45- and 90-degree angulations from the midsagittal plane by Mupparappu

CASE REPORTS: A 20-year-old man reported to the Department of Oral Medicine and Radiology, I.T.S dental college, Greater Noida, India, with a chief complaint of mobile tooth in mandibular anterior tooth region. Panoramic radiographic examination revealed that the canines were bilaterally transmigrating. The mandibular right canine appeared to be inferiorly positioned compared to the mandibular right canine. (Fig 3)



Fig. 3: Type III subtype A. Transmigrating canines positioned one above the other in the symphyseal region. The canine inclination is close to 90 degrees from the midsagittal plane

A 45-year-old man reported to the Department of Oral Medicine and Radiology, I.T.S dental college, Greater Noida, India, with a chief complaint of mobile tooth in mandibular anterior tooth region. Panoramic radiographic examination revealed that the canines were bilaterally transmigrating. The mandibular right canine appeared to be inferiorly positioned compared to the mandibular right canine. (Fig 4)



Fig. 4

A 23-year-old man reported to the Department of Oral Medicine and Radiology, I.T.S dental college, Greater Noida, India, with a chief complaint of missing tooth in mandibular anterior tooth region. Panoramic radiographic examination revealed showed bilaterally transmigrating mandibular canines in the symphyseal region, with impacted incisors. For relevant positioning of central, lateral incisors and canines patient was subjected to CBCT. (Fig. 5 & 6)



Fig. 5: Type I subtype A. Bilaterally transmigrating mandibular canines near the symphysis region. The right canine is crossing the midline, and the left canine is near the midline.





Fig. 6: CBCT image shows:33 & 43 - Oblique mesioangular impaction is noted in the sub-crestal region of alveolus with incisal edge of crown indenting the alveolar crestal region in the midline mandible. 32 & 42 - Oblique vertical impaction noted in left anterior mandibular midline region, on the labial aspect of crown of impacted tooth 33 & 43.


DISCUSSION: Though the etiology and exact mechanism of transmigration is still not clear, over the years various probable factors have been associated. These are anomalous position of tooth germ,9 displacement of dental lamina in the embryonic life,10,11 strong eruption force,5,6 agenesis of the adjacent teeth,12 premature loss of deciduous teeth,3 retention of canines,12 crowding,1 spacing,12 supernumerary teeth, excessive length of crown1, bony pathology resembling a cystic lesion,2,13,14,15 tumors, cysts, odontomas,16 genetic role,17,18 fracture10 and idiopathic causes. Howard observed that impacted mandibular canines that lie between 25 and 30 degree in the midsagittal plane do not migrate across the midline whereas between 30 and 95 degree tend to cross the midline.19 Vichi et al12 proposed that proclination of the lower incisors, increased axial inclination of the unerupted canine and an enlarged symphyseal cross-sectional area of the chin may be favourable conditions for transmigration. Studies have shown that bilateral transmigration of canines is rare. In the context of bilaterally transmigrating mandibular canines, it is essential to study the canines based on the eruption status, pattern of migration, and projected eruption path. Mupparapu classification helps to predict the eventual eruption pattern of solitary mandibular canines that are transmigrating. (Table 1 & 2) A total of 14 cases of bilateral mandibular canine transmigrations were previously reported in the English literature and 3 new cases are added with this report. (Tables 3 & 4) From the literature review, the most common type of bilateral canine transmigration noticed was type I subtype A (60%), followed by type III subtype A (22%) and type II subtype A (9%). In our case reports 2 were type III subtype A, 1 was type 1 subtype A. Type II bilateral transmigrations may be candidates for guided eruption as well as orthodontic repositioning on the opposite side of the arch, as the inclination of the long axis is more favorable for orthodontic treatment, provided the teeth attempt to erupt in the region of the opposite canine. Type I and type III bilateral transmigrations are difficult to treat orthodontically because of their positional inclination within the mandible.20 Qaradaghi21 had name “kissing canines”or “mirror image canines” which is defined as the migration of both canines at the same rate and on the same horizontal axis parallel to each other and meeting each other at the midline. (Figure 7) A proper documentation and categorization of the patterns of eruption would help the clinician formulate appropriate treatment to restore esthetics and function without loss of any natural teeth. Transmigration of the permanent canine is a rare dental anomaly. It is important to diagnose this condition at earlier stages of migration to prevent more complex problems. Clinicians should be encouraged to report more cases of this condition to enable further classification and a better understanding of this rare anomaly.


Type I

Canine positioned mesio-angularly across the midline, labial or lingual to the anterior teeth.

Type 2

Canine horizontally impacted near the inferior border of the mandible inferior to the apices of the incisor teeth.

Type 3

Canine erupting on the contralateral side.

Type 4

Canine horizontally impacted near the inferior border of the mandible below the apices of posterior teeth on the contralateral side.

Type 5

Canine positioned vertically in the midline with the long axis of the tooth crossing the midline.

Table 1: Mupparapu’s proposed classification of unilaterally transmigrating mandibular canines




Type I


Mandibular canines transmigrate across the midline, and the final position is around the midsymphyseal region with most of the crown and root portions on the opposite side of the midsagittal plane with a long-axis inclination of less than 45 degrees to the midsagittal plane (Fig 6).

Subtype A

Only 1 canine completely crosses the midline and the other canine is just at the midline, or both partially cross the midline.

Subtype B

Both canines completely cross the midline.

Type II

Mandibular canines transmigrate across the midline, and the final position of the canines is anywhere between the midline and the canine region of the opposite side with a long-axis inclination of 45 to 90 degrees to the midsagittal plane

Subtype A

Only 1 canine completely crosses the midline and the other canine is just at the midline, or both canines partially cross the midline.

Subtype B

Both canines completely cross the midline.

Type III

Mandibular canines transmigrate across the midline having a long-axis inclination of about 90 degrees. Essentially, the teeth are horizontally positioned within the body of the mandible. The final position of both transmigratory canines may vary anywhere from the midsymphyseal region to the opposite canine region or beyond

Subtype A

Canines are positioned within the symphysis region, one above the other.

Subtype B

Canines are within the body of the mandible but occupy a distinct and separate position on opposite sides beyond the midsymphyseal region, far from their ideal position within the arch.

Table 2: Mupparapu’s proposed classification of bilaterally transmigrating mandibular canines



CASE NO.

AGE

SEX

AXIAL INCLINATION

TYPE

RETAINED DECIDUOUS

DENTAL ANOMALIES

ASSOCIATED PATHOLOGIES

1.

20

M

90 DEGREE

TYPE III SUBTYPE A

RETAINED 73,83

-

-


2.


45

M

90 DEGREE

TYPE III SUBTYPE A

RETAINED 73,83

-

-

3.


23

M

45 DEGREE

TYPE1 SUBTYPE A

RETAINED 73,83

IMPACTED 32,42

-

Table 3: Clinical and radiographic features of transmigrated mandibular

canines observed in the present series of 3 patients






Author

Journal/year

Categorization using the proposed classification

No. Of cases reported

Associated pathology

Cowman and Wooton20

N Z Dent J, 1979

Type I subtype A

1

None

Joshi et al21

Br J Orthod, 1982

Type III subtype A

1

None

Joshi MR27

Angle Orthod, 2001

Type I subtype A

1

None

Al-Wahedi12

Quintessence Int, 1994

Type III subtype A

1

none

Javid22


Int J Oral Surg, 1985

Type I, subtype A (final positions not

reported for 2 cases)



3

none

Jalili23

J Indian Dent Assoc, 1986

Type I subtype B

1

none

Gadgil24


Oral Surg Oral Med Oral pathol 1986

Type I subtype A

1

All incisors impacted impacted along transmigrated canines

Mehta et al25

J Indian Dent Assoc, 1986

Type I subtype A

1

none

Kuftinec et al26

J Am Dent Assoc, 1995

Type I subtype A

1

none

Aydin and Yilmaz2

Dentomaxillofac Radiol, 2003

Type III subtype A

1

none

Mupparapu et al

Quintessence Int, 2007

Case 1: Type I subtype A

Case 2: Type II subtype A

Case 3: Type III subtype A

Case 4: Type I subtype A

Case 5: Type I subtype A


5

Case 3: Cyst

associated with the

crown of the left

canine; none associ-

ated with remainder


Idris Faiq Qaradaghi

Rev Clín Pesq Odontol. 2010

Case 1: Type 1 subtype A

Case 2: Type 1 subtype A



2

None

Table 4: Characteristics of previously reported and new cases of bilaterally

transmigrated mandibular canines







Fig. 7: Both lower canines have crossed the midline and kissed each other with labial surfaces


REFERENCES:

  1. Nodine AM. Aberrant teeth, their history, causes and treatment. Dent Items Interest. 1943; 65: 440–451.

  2. Thoma KH. Oral Surgery. 2nd ed. St Louis, Miss: CV Mosby; 1952.

  3. Ando S, Aizawa K, Nakashima T, Sanka Y, Shimbo K, Kiyokawa K. Transmigration process of the impacted mandibular cuspid. J Nihon UnivSch Dent. 1964; 6: 66–71.

  4. Tarsitano JJ, Wooten JW, Burditt JT. Transmigration of nonerupted mandibular canines: report of cases. J Am Dent Assoc. 1971; 82:1395–1397.

  5. Javid B. Transmigration of impacted mandibular cuspids. Int J Oral Surg. 1985; 14: 547–549.

  6. Joshi MR, Shetye SB. Transmigration of mandibular canines: a review of the literature and report of two cases. Quintessence Int.1994; 25: 291–294.

  7. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985; 59: 420–425.

  8. U Aydin, HH Yilmaz and D Yildirim; Incidence of canine impaction and transmigration in a patientpopulation; Dentomaxillofacial Radiology (2004) 33, 164–169.

  9. 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: 395–398.

  10. Mitchell L. Displacement of a mandibular canine following fracture of the mandible. Br Dent J. 1993; 174: 417–418.

  11. Nixon F, Lowey MN. Failed eruption of the permanent canine following open reduction of a mandibular fracture in a child. Br Dent J. 1990; 168: 204–205.

  12. Vichi M, Franchi L. The transmigration of the permanent lower canine. Minerva Stomatol. 1991; 40: 579–589.

  13. Fiedler LD, Alling CC. Malpositioned mandibular right canine: report of case. J Oral Surg. 1968; 26: 405–407.

  14. Greenberg SN, Orlian AI. Ectopic movement of an unerupted mandibular canine.J Am Dent Assoc. 1976; 93: 125–128.

  15. Wertz RA. Treatment of transmigrated mandibular canines.Am J Orthod Dento facial Orthop. 1994; 106: 419–427.

  16. Shapira Y, Mischler WA, Kuftinec MM. The displaced mandibular canine.ASDC J Dent Child.1982; 49: 362–364.

  17. Peck S. On the phenomenon of intraosseous migration of nonerupting teeth. Am J OrthodDentofacialOrthop.1998; 113: 515–517.

  18. Baccetti T. A controlled study of associated dental anomalies.Angle Orthod.1998; 68: 267–274.

  19. Howard R. The anomalous mandibular canine. Br J Orthod. 1976; 3 (2): 117-21.

  20. Muralidhar Mupparapu. Patterns of intraosseous transmigration and ectopic eruption of bilaterally transmigrating mandibular canines: Radiographic study and proposed classification. Quintessence Int 2007; 38: 821–828.

  21. Idris Faiq Qaradaghi. Bilateral transmigration of impacted mandibular canines: report of two cases and review. Rev Clín Pesq Odontol. 2010 set/dez; 6 (3): 271-5.




AUTHORS:

  1. Achint Garg

  2. Suraj Agarwal

  3. Shweta Agarwal

  4. Samta Mittal

  5. Parul Singh


PARTICULARS OF CONTRIBUTORS:

  1. Professor & HOD, Department of Oral Medicine & Radiology, I. T. S. Dental College, Hospital & Research Centre, Greater Noida.

  2. Post Graduate Student, Department of Oral Medicine & Radiology, I. T. S. Dental College, Hospital & Research Centre, Greater Noida.

  3. Post Graduate Student, Department of Oral Medicine & Radiology, Rama Dental College, Kanpur.



  1. Senior Lecturer, Department of Oral Medicine & Radiology, I. T. S. Dental College, Hospital & Research Centre, Greater Noida.

  2. Senior Lecturer, Department of Oral Medicine & Radiology, I. T. S. Dental College, Hospital & Research Centre, Greater Noida.


NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Achint Garg,

Garg Dental Care,

# 101, Moulsani Orcade,

DLF City, Phase-3, Gurgaon-122002.

E-mail: achintgarg@yahoo.com

Date of Submission: 06/01/2015.

Date of Peer Review: 07/01/2015.

Date of Acceptance: 09/01/2015.

Date of Publishing: 13/01/2015.





J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 7/Feb 16, 2015 Page




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