J Oral Maxillofac Surg

68:996-1000, 2010

Use of Panoramic X-Ray to Determine

Position of Impacted Maxillary Canines
Alexander Katsnelson, DMD, MS,*
William G. Flick, DDS, MPH, Seenu Susarla, DMD, MPH,
Julia V. Tartakovsky, BS, and Michael Miloro, DMD, MD
Purpose: To evaluate the position of impacted maxillary canines in the alveolus using panoramic

radiographs.
Materials and Methods: The present study was a retrospective chart review of 102 patients with 130

impacted maxillary canines from the University of Illinois at Chicago College of Dentistry and private
practice. Of the 130 impacted maxillary canines, 59 were impacted buccally and 71 were impacted
palatally. The inclination of the impacted maxillary canines to a horizontal line from the mesiobuccal
cusps of the maxillary molars was measured. We used these measurements to predict the position of the
tooth and correlate this prediction with the actual approach used during surgery.
Results: The mean angulation of the buccally impacted maxillary canines was 75.1 18.2 (range, 8
to 111). The mean angulation of the palatally impacted maxillary canines was 51.3 15.3 (range, 12
to 91). The mean difference between the angulation of the impacted maxillary canines as measured
on the panoramic radiographs was statistically significant (P .001). From a receiver-operator characteristic curve and using a logistic regression model, impactions greater than 65 were 26.6 times more
likely to be buccally impacted maxillary canines (P .001).
Conclusions: Panoramic radiographs are useful for predicting the location of impacted maxillary
canines and the subsequent surgical approach required for exposure and orthodontic appliance attachment when computed tomography is unavailable or unnecessary otherwise. The use of panoramic
radiographs for determing impacted maxillary canine position has a high sensitivity and specificity, with
angulations greater than 65 associated with buccal impactions.
2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights
reserved.
J Oral Maxillofac Surg 68:996-1000, 2010
Maxillary canines are the second most common impacted teeth after the third molars. According to
Bass,1 the frequency of the impaction of canine teeth
is 2%. Dachi and Howell2 reported that the incidence
of maxillary canine impaction is 0.92%, and Thilander
and Myberg3 estimated the cumulative prevalence of
canine impaction at 2.2%. The incidence of impacted
canines is also different in diverse populations. In a
Saudi population, the incidence was estimated to be
3%,4 and in a Swedish population, the incidence was
reported as 1.7%.3 Impactions are twice as common
in females (1.17%) than in males (0.51%). It has been
estimated that 8% have bilateral impactions.4
The canines determine the occlusion, stability, form,
and function of the arch.5 Therefore, the treatment of
choice is first performed by exposure and bonding of
the canines by the surgeon, and then these teeth are
brought out to the alveolus by the orthodontist.
Surgical exposure and bonding are done by approaching the tooth from the buccal or palatal side of
the alveolus. A buccal location of the tooth is defined

*Resident, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.
Clinical Associate Professor, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago College of Dentistry,
Chicago, IL.
Resident, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.
Masters Student, Harvard University, Cambridge, MA.
Professor and Head, Department of Oral and Maxillofacial
Surgery, University of Illinois at Chicago College of Dentistry,
Chicago, IL.
Address correspondence and reprint requests to Dr Miloro:
Department of Oral and Maxillofacial Surgery, University of Illinois
at Chicago College of Dentistry, 801 S Paulina St, MC 835, Chicago,
IL 60611; e-mail: mmiloro@uic.edu
2010 American Association of Oral and Maxillofacial Surgeons. Published

by Elsevier Inc. All rights reserved.

0278-2391/10/6805-0008$36.00/0
doi:10.1016/j.joms.2009.09.022

996

997

KATSNELSON ET AL

FIGURE 1. Analysis of panoramic x-ray.

Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

The method we tested in our study included a

single panoramic radiograph. Because almost every
patient with an impacted maxillary canine will already
have had a panoramic radiograph taken at the initial
diagnosis, it would be advantageous to be able to
determine the buccal or palatal position from this
radiograph. Our hypothesis was that the measurements of the tooth angle in relationship to the occlusal plane could be used to predict the buccal or
palatal position of the impacted canine.

Materials and Methods

as a canine that is closer to the buccal cortex of the
maxilla and, therefore, access is easier on the buccal
vestibular side. A palatal inclination means that the
canine is close to the palatal cortex, and the best
approach will be through the palatal mucosa. Palatal
impaction of maxillary canines is more common than
buccal impaction. In general, 85% of patients have
presented with a palatal inclination and 15% with a
buccal inclination.6 Caprioglio et al7 reported a ratio
of 1:3 for buccal to palatal displacement.
To decide which approach to select, the surgeon
must localize the impacted canine. This can be done
using several methods. The tooth can be localized by
clinical examination. The crown of the impacted canine can sometimes be palpated. However, the canine
eminence can be confused with the impacted tooth.
If the canine is palatally placed, it might press on the
root of the lateral incisor and push the root buccally,
with the crown moving palatally. The other option is
to localize the tooth using 2 periapical x-rays, according to the buccal object rule, or the rule of same
lingual opposite buccal, introduced by Clark8 in
1910. This method involves 2 radiographs using the
same vertical angulations but taken at different horizontal angles. Owing to parallax, the more distant
object will appear to travel in the same direction as
the tube shift, and the object closer to the tube will
appear to move in the opposite direction. Various
combinations of x-rays can be used: 2 periapical,9 1
maxillary occlusal and 1 periapical, or 1 panoramic
and 1 maxillary anterior occlusal view.10
The third option is to localize the tooth according
to the magnification. Chaushu et el11 suggested that
the mesiodistal dimensions of the canine and the
homolateral central incisors can be measured from a
single panoramic radiograph. If the relationship between the sizes of the canine to the central incisors is
1.15 or greater, a palatal displacement is suggested.
The fourth option is to use a computed tomography
(CT) scan, which can help to localize the tooth, as
well as give additional information regarding any
bony pathologic features associated with the impacted tooth.12

The present study was a retrospective chart review.

The study sample was derived from patients treated at
the University of Illinois at Chicago College of Dentistry or at the private oral and maxillofacial practice
of one of the authors (W.G.F.). The inclusion criteria
were that the patient had undergone exposure and
bonding of at least 1 maxillary canine from 2004 to
2008.
The study variables incorporated the patients age
and gender. The anatomic measure was the angulation of the canine to the occlusion plane according
the panoramic x-ray. A horizontal line was drawn
from the mesiobuccal cusp tip of the right and left
maxillary first molars, and along the long axis of the

FIGURE 2. A, Example of panoramic x-ray of buccally located

maxillary canines. B, Example of panoramic x-ray of palatally
located maxillary canines.
Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

998
impacted canines (Figs 1, 2). The inclination of the
canine as measured lateral to the midline was recorded in degrees. For unilateral impactions, one angle was recorded, and for bilateral impactions, the
angulations of both teeth were recorded. The primary
outcome variable was the location of the impacted
canine, which could be closer to the buccal cortex
(buccally impacted) or palatal cortex (palatally impacted).
Data were entered into a spreadsheet during the
study period and analyzed using a commercially available statistical software package (Statistical Package
for Social Sciences, version 11.0; SPSS Inc, Chicago,
IL). Descriptive statistics were computed to establish
the distribution of angulations for buccally and palatally impacted canines. The mean angulations for both
groups were compared using nonparametric methods, given the lack of confirmed normality within the
sample. A scatterplot was used to identify various
thresholds for a diagnostic test for buccal impaction.
Diagnostic test characteristics (ie, sensitivity, specificity, positive and negative predictive values) were
computed for each threshold. A receiver operating
characteristic curve was constructed to compare the
various thresholds. Logistic regression analysis was
used to compute the odds of buccal impaction. For all
analyses, a P value less than .05 was considered statistically significant.

Results
During the study period, from 2004 to 2008, 102
subjects underwent exposure and bonding of the upper
canines. Of the 130 canines, 67 were on the right and 63
were on the left. In 28 patients, the maxillary canines
were bilaterally impacted (27.4%).
Of the 130 teeth, 59 were in the buccal group and
71 were in the palatal group (Figs 2A,B, Table 1). The
angulation of the canines in the buccal group was
75.1 18.2 (range, 8 to 111) and in the palatal
group was 51.3 15.3 (range, 12 to 91). A
scatterplot was used to demonstrate the angulations (Fig 3).
The specificity, sensitivity, positive predictive
value, and negative predictive value were then generated for data ranges of greater than 60, greater than
65, and greater than 70 (Fig 4, Table 2). These data
were then used to generate a receiver operating characteristic curve, which demonstrated that the best
combination of sensitivity and specificity was for impactions of greater than 65. From the receiver operating characteristic curve and using a logistic regression model, it was shown that angulations of
impactions greater than 65 were 26.6 times more
likely to be buccal (95% confidence interval 10.4 to
76.9, P .001).

PANORAMIC X-RAY OF IMPACTED MAXILLARY CANINES

Table 1. DESCRIPTIVE STATISTICS FOR

STUDY POPULATION

Location of Impaction
Buccal (n 59) Palatal (n 71)

Angulation
Mean SD
75.1 18.2
Range
8-111
Angulation frequency
10
1 (1.7)
11-20
0 (0.0)
21-30
2 (3.4)
31-40
0 (0.0)
41-50
2 (3.4)
51-60
2 (3.4)
61-70
9 (15.3)
71-80
14 (23.7)
81-90
23 (39.0)
91-100
5 (8.5)
101-110
0 (0.0)
111-120
1 (1.7)

51.3 15.3
12-91

P
Value
.001

0 (0.0)
2 (2.8)
1 (1.4)
12 (16.9)
18 (25.4)
23 (32.4)
7 (9.9)
5 (7.0)
2 (2.8)
1 (1.4)
0 (0.0)
0 (0.0)

Data in parentheses are percentages.

Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

Discussion
The purpose of the present study was to evaluate
whether we can find the best surgical approach for
exposure of the maxillary canine using angulation of
the canine obtained from the panoramic x-ray. We
hypothesized that a correlation would be found between the angle of the canine to the occlusal line and
the proximity to the buccal or palatal side of the
maxillary alveolus. With regard to this hypothesis,
the specific aims were to measure the angulation of
the impacted canine and compare the buccally and
palatally located teeth.
The mean angle was 75.1 for the buccal group and
51.3 for the palatal group. From the receiver operating
characteristic curve and using a logistic regression
model, it was shown that an angulation of an impacted
maxillary canine greater than 65 was 26.6 times more
likely to reflect a buccally impacted maxillary canine
than a palatally impacted maxillary canine.
The study by Mason et al13 compared 2 techniques
for the localization of impacted maxillary canines:
vertical parallax and magnification. They found that
localization with vertical parallax was more successful (76%) than localization with magnification
(66%). These differences were not statistically significant. Also, palatally impacted canines could be
correctly detected using either technique in 90% of
the cases, but buccal localization could be detected
with much less precision (parallax method 46% and
magnification method 11%). The magnification
method also has limitations when the canine is

999

KATSNELSON ET AL

FIGURE 3. Scatterplot of canine angulation stratified by type of impaction demonstrating significant variance in distribution of angulations
associated with buccally impacted teeth versus palatally impacted teeth.
Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

rotated, in contact with the incisor root, or the

incisor root has not tipped.
Jacobs14 advocated that the horizontal tube shift
between 2 occlusal films is a more sensitive method

of localizing canines than the vertical tube shift,

which uses panoramic and occlusal films. Wolf and
Mattila15 proposed a rule that if a canine is superimposed on the root of the central incisor, it is located

FIGURE 4. Receiver operating characteristic curve demonstrating that diagnostic test threshold resulting in best combination of sensitivity and
specificity is 65. Using angulations greater than 65 as positive test for buccal angulation, sensitivity and specificity was 0.81 and 0.86,
respectively. In a logistic regression model, angulations greater than 65 were 26.6 times more likely to indicate buccal impaction (95%
confidence interval 10.4 to 76.9, P .001).
Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

1000

PANORAMIC X-RAY OF IMPACTED MAXILLARY CANINES

Table 2. DIAGNOSTIC TEST CHARACTERISTICS FOR

VARIOUS THRESHOLDS

Threshold
Variable

60

65

70

Specificity
Positive predictive
value
Negative
predictive value
Sensitivity

0.79

0.86

0.89

0.78

0.83

0.84

0.89
0.88

0.85
0.81

0.84
0.8

Katsnelson et al. Panoramic X-Ray of Impacted Maxillary Canines. J Oral Maxillofac Surg 2010.

palatally. However, Jacobs14 reported a case that was

an exception to this rule.
Overall, no method to date has been adequate,
except for using CT, which can depict the location of
the impacted maxillary canine. However, CT has its
disadvantages owing to the large amount of radiation
to the patient, as well as the financial burden.
The present study had significant strengths and
weaknesses that should be mentioned to provide the
appropriate background for the interpretation of the
results. The strengths of our study included the large
sample size, allowing adequate power for analysis
using multiple covariates and a minimal bias (in particular, selection and recall biases). One of the weaknesses of the present study was related to the study
design. The ideal method to compare the localization
of the canine in the alveolus would be to compare the
panoramic x-ray findings with those from CT scan.
However, that would have necessitated obtaining a
CT scan for each of our patients, which was not
feasible. Therefore, to determine whether the canine
was located buccally or palatally, we derived the location of the canine from the surgical log, which
mentioned the approach used. The surgeons used the
approach that seemed the most appropriate for each
case. However, if the surgeons could not find the
canine, they opened a flap at the opposite side. In our
case study, we recorded the actual approach used to
expose the canine.

One possible explanation for why the angle correlates with the location of the canine is that if the tooth
is in the palatal position, it is positioned horizontally
in the sagittal plane at the palate and cannot be
positioned vertically because the palatal bone is thin
in the sagittal dimension.
In conclusion, the results of our case study suggest
that the angulation of impacted maxillary canines can
be reliably obtained from a single panoramic x-ray.
Also, our findings indicate that angulations greater
than 65 were 26.6 times more likely to reflect buccally impacted maxillary canines than palatally impacted maxillary canines.

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