2021, Number 1
Lower canine transmigration. A clinical case report
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ABSTRACT
Teeth retention is the eruption delayed. Except for third molars and uppers canines, the retention is an unusual condition, as well as the intraosseous migration of retained teeth. Transmigration is an anomaly in which a tooth migrates across the midline. Diagnosis of these pathologies is produced by radiographic findings and involves multiple treatments such as extraction or orthodontic positioning. Dental transmigration is asymptomatic mainly, although it can cause serious complications such as root resorption of adjacent teeth, damage to anatomical structures, tooth malposition, midline deviation, and agenesis. Therefore, early diagnosis with routine X-ray is essential to detect it. The present case describes the evolution of a patient between eight and 12 years old with a transmigrant mandibular canine; additionally, a literature review focused on treatment was done.INTRODUCTION
Altered tooth eruption is characterized by the failure of the tooth to erupt in the proper position, which can cause impaction, translocation, or transmigration.1 Except for third molars, the retention of a tooth is a rare condition; the intraosseous migration of retained teeth is also an unusual dental anomaly.2,3 Dental transmigration is the migration of unerupted teeth across the midline.2,4-7 The literature describes canine transmigration as a phenomenon in which it crosses the mandibular midline beyond its half-length1 or more than half-length of the crown.3
Several etiological factors are associated with transmigration, such as premature loss of primary teeth, retention of the temporary canine, odontomas, crowding, supernumerary teeth, and excessive canine coronal length.5 In addition, disorders of bone resorption and apposition are a direct cause of transmigration, together with a metabolic activation of a different area of the dental follicle in the canine germ, which would give a different eruption route.8 However, the etiology and the exact mechanism are still unclear.5 Transmigration of a tooth germ occurs more often during the maturation phase when the alveolar processes grow intensively.
Transmigrant teeth usually do not cause symptoms.6 Therefore, the patients are not aware of this condition y they are usually detected during routine radiological examinations.3,7 This paper aims to present a clinical case and, additionally, a review of the literature regarding the lower canine transmigration focus on the treatments to follow.
CASE REPORT
In 2015, a 12-year-old patient went with his mother to the Universidad de Concepción Pediatric Dentistry Clinic for a routine examination. The patient had previously attended dental check-ups in the private area, and imaging tests were performed since 2012 that evaluated the development of dentition (Figure 1).
Intraoral examination shows the patient in a mixed dentition status, with the absence of the dental organ (DO) 4.3, with bulging of the vestibular cortex from DO 4.2 to 3.2 regions. Cone Beam tomography (CBCT) and panoramic radiography were requested and examined, observing DO 4.3 retained in the anterior-inferior area of the mandible, with a frank mesial version, slightly widening pericoronal sac, associated with disruption of the vestibular cortex (Figure 2).
The root is in the center of the ridge and the vestibular coronal area in relation to DO 3.1 and 3.2. No images suggest abnormal root resorption at the lower incisors level (Figure 3). The canine has already crossed the midline and is in a very advanced stage of development. As it has almost completed the root formation, efforts to perform orthodontic treatment and position the piece correctly are almost non-existent; therefore, the treatment was tooth extraction, ruling out transplantation due to the absence of the existing interdental space.
The extraction of the piece is indicated, but the patient does keep his surgery appointment. One year later, in August 2017, he returned to the consultation. Using a CBCT, the disposition adopted by the transmigrant upper canine can be appreciated (Figure 4).
In all appointments, the parents were informed of the importance of performing the canine extraction and its possible consequences and the informed consent for the publication of the case. In January 2019, the patient undergoes a canine extraction to avoid damage to the associated teeth, and after six months of radiographic control, the adjacent teeth are intact and without color changes clinically (Figure 5).
Orthodontic treatment is indicated pending the definitive treatment with a dental implant to replace the canine to finalize the case.
DISCUSSION
The classification for intraosseous transmigration and ectopic eruption of lower canines according to their migratory pattern and mandibular position with respect to the dental midline, describes five types,2 being type 1 the most frequent.5 The case described corresponds to the type 1 pattern, related to dental organs 3.1 and 3.2 and its longitudinal axis is in a mesial inclined position. This case presents a unilateral migration that according to the current literature is more common than bilateral migration. Likewise, the lower left canine is affected more frequently and mostly in women than in men3,5,6,9 –in the specific case it corresponds to a male–. The reason for the gender predilection is not clear, it is believed that it is because women tend to consult more frequently due to the complications in aesthetics that arise.10
The patients with canine transmigration are often characterized by hypodontia of lower lateral incisors or of second premolar, defects in the enamel development, reduced number of teeth, or retained upper canines.5,8 However, in the present case there was no resorption of the roots of the adjacent teeth or other associated pathologies, except for the exfoliation of the temporary piece in the last control recorded.
Sharma and Nagpal10 suggested that the angulation of the longitudinal axis of the unerupted canine concerning the sagittal midplane should always be evaluated in the mixed dentition period, as early and timely intervention leads to better management of the transmigrated canine and, in consequence, avoids possible complications associated with the migration of the canine across the midline.3
Analyzing the degree of canine inclination on a panoramic radiograph is helpful in the early diagnosis of transmigration. The angle of canine inclination between 30o and 50o can indicate the presence of transmigration. When greater than 50o, it would indicate a clear future transmigration.8 Figure 1 shows a slight mesioinclination of the lower canines; however, they are not conclusive or lead to suspect future transmigration in our case.
According to Koszowski et al.,6 20% of all canines erupt in the midline, or on the opposite side of the dental arch, usually towards the vestibular cortex. In the most extended recorded case of displacement, a canine migrated to the mesial root of the first molar. The distance of migration is variable.6 In this case, due to the horizontal position and the long-distance travel, it is concluded that the chances of an eruption are almost nil, and for this reason, the extraction of the canine was recommended.
In literature there is a wide range of treatments including extraction, orthodontic treatments, transplantation and observation. The treatment depends on radiographic position, tooth maturity, clinical signs, patient goals, overall dental treatment plan and especially, the possibilities of eruption. However, in most of cases treatment involves the extraction in case of an unerupted tooth.2,3
Specifically, it is suggested that in case the canine crown has migrated beyond the contralateral incisor, or if the vertex has migrated beyond the cusp of the adjacent lateral incisor, it may be mechanically impossible to bring the canine into its correct position.2
In the present case, surgical extraction of the transmigrant canine and subsequent controls of a possible closure of the space were carried out, pending the definitive implant replacement treatment, once the patient's growth is over.
CONCLUSION
Diagnosis, evaluation and treatment of canine transmigration are essential to prevent related complications, both in aesthetics and functions. By early recognition of dental anomalies, many complications can be avoided, mainly referred to avoid tooth extraction.
The ideal treatment to follow in this specific case is to extract the tooth and the inflamed dental follicle, with a subsequent orthodontic treatment to stabilize the arches, in order to provide an aesthetic and definitive solution through a dental implant, once the growth of the patient is finished.
REFERENCES
AFFILIATIONS
1 Departamento de Pediatría Bucal, Facultad de Odontología de la Universidad de Concepción, Chile.
CORRESPONDENCE
Antonieta Pérez-Flores. E-mail: mperezf@udec.clReceived: Agosto 2019. Accepted: Marzo 2020.