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The Open Dentistry Journal

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RESEARCH ARTICLE

Use of 3D Imaging for Treatment Planning in Cases of Impacted Canines

Marco Portelli*, Riccardo Nucera, Rosamaria Fastuca, Marco Cicciù, Antonino Lo Giudice and Angela Militi

Department of Biomedical, Dental Science and Morphological and Functional Images, Dental School, University of Messina, Messina, Italy

Abstract:
Background:
The use of 3D imaging offers the possibility to improve diagnosis and treatment planning in several fields of dental science.

Objective:
The aim of this study is to evaluate the usefulness of 3D evaluation for surgical exposure treatment planning in cases of impacted canine.

Methods:
This retrospective study has been conducted on the clinical reports of twenty patients (11 F - 9 M) with a mean age of 15.4 years, affected by the
impacted canine. Each patient underwent a CBCT exam (Hitachi MercuRay, Hitachi Medical Technology, Tokyo, Japan), in order to obtain
sagittal, axial and coronal images and a 3D surface rendering. The images have been evaluated by 14 experts orthodontists who were divided into
two groups. The first group first evaluates the bidimensional images and then the 3D images and the second group instead has done exactly the
opposite. Each orthodontist has elaborated a treatment plan for the impacted canine correction with a specific indication about surgical exposure
approach (Palatal-Vestibular) and orthodontic biomechanics.

Results:
The level of concordance in treatment planning of the 3D images evaluation and the bidimensional images was found to be greater in the second
group of orthodontists. Moreover, in this group, the time spent for the treatment plan has been lower than in the first group (12 ± 3.32 min vs. 23 ±
2.53 min, p < 0.05).

Conclusion:
According to the results of the present study, it is possible to state that CBTC is fundamental for the diagnosis and treatment planning of impacted
canine. However, further studies are necessary to confirm the greater reliability of 3D surface rendering compared to the bidimensional images.

Keywords: Alveolar bone remodeling, Bidimensional imaging, Cone beam technology, Dental anomalies, Impacted canine, 3D rendering.

Article History Received: November 27, 2018 Revised: February 26, 2019 Accepted: March 19, 2019

1. INTRODUCTION In the beginning, it is necessary that permanent teeth go along

the physiologic way of the eruption, reabsorbing the root of the
Permanent teeth eruption represents the final step of a
deciduous tooth. However, several local or systemic factors can
complex series of events controlled by genetic and epigenetic
get in the way of permanent teeth eruption producing dental
patterns. In most cases, tooth bud, after coronal development,
impaction [1]. The genetic component of tooth impaction can
erupts in oral cavity reaching the occlusal plane. At this point,
be investigated by evaluating the associated dental anomalies.
the dental element is affected by occlusal and masticatory
The impacted teeth can be infact associated to other dental
stresses, therefore active eruption breaks. Dental eruption is anomalies and in particular with tooth transposition and
related to both root development and alveolar bone remodeling. supernumerary tooth [2].
*
Address correspondence to this author at the Department of Biomedical, Dental This clinical eventuality produces in the absence of one or
Science and Morphological and Functional Images Dental School, Faculty of
more teeth over the physiologic period. It is necessary to
Medicine, University of Messina, Via Consolare Valeria, Gazzi, C.A.P. 98100
Messina, Italy; Tel: 0039090/2216910; Fax 0039090/2216911; distinguish dental impaction and dental retention. In this last
E-mail: mportelli@unime.it case, even if the tooth has not erupted within the physiologic

DOI: 10.2174/1874210601913010137, 2019, 13, 137-142

138 The Open Dentistry Journal, 2019, Volume 13 Portelli et al.

time, the root is yet to be developed. So a delayed eruption can The aim of this study is to evaluate the usefulness of 3D virtual
be expected. Dental impaction may affect one or more teeth, imaging of dental elements for the treatment planning in cases
deciduous or permanent, and can be endoosseus or sub- of impacted canine [12, 13].
mucosus. In this last case, it is possible to distinguish a total or
a partial inclusion, depending on the presence of a complete or 2. MATERIALS AND METHODS
a partial mucosus coating of the dental element. Epidemio- This retrospective study has been performed on the clinical
logical studies reported a mean incidence of dental impaction reports of twenty patients (11 F, 9 M), afferent to the
equal to 20% in developed populations, especially in the Department of Orthodontics at the University of Messina, from
European one with prevalence in the female sex. The most March 2015 to May 2018, and affected by maxillary cuspid
affected tooth is the mandibular third molar followed by the inclusion. For each patient, informed consent has been acquired
maxillary third molar and the maxillary canine. Canine for the treatment through an apposite validated model. In the
bilateral impaction occurs only in 8-10% of cases. Even if the study group, 29 impacted canine has been recorded in total, in
development of canine germ occurs in a vestibular position in 9 bilateral cases. The age of the patients selected was between
the adjacent teeth, canine impaction is palatal in 75% of cases. 12, 8 and 26, 8 ages (mean 15, 4 ± 2.4). Exclusion criteria
The agenesis of a permanent canine is extremely rare in non- were: Dental anomalies, craniofacial deformities, incomplete
syndrome patients. In cases of syndromic canine agenesis, root development and previous orthodontic treatments. The
instead, early detection of the associated medical conditions is canine impaction diagnosis has been made on the basis of
extremely important [3]. The therapeutic approach to canine clinical evidence that permanent cuspid has not erupted beyond
impaction is multidisciplinary and involves several specialists the physiological period and through a radiological examina-
such as an orthodontist, oral surgeon and periodontologist. tion. The orthodontic check-up was carried out for the patients,
Treatment planning is based on several items such as the comprehended intra and extra-oral photos, Orthopano-ramic X-
position of the canine, the surgical accessibility and the Ray and impressions in alginate of both the arches in order to
prognosis of the intervention, both on the impacted tooth and obtain dental casts. After the diagnosis of impacted canine,
on the adjacent teeth [4]. Treatment planning is carried out on each patient underwent a CBCT exam (Hitachi MercuRay,
the basis of bidimensional [5] and three dimensional [6 - 8] Hitachi Medical Technology, Tokyo, Japan), in order to obtain:
radiological investigations. The new frontier in dental imaging
is represented by Cone Beam Technology. The use of 3D Sagittal (Fig. 1), Coronal (Fig. 2) and Axial (Fig. 3)
imaging gave the possibility to improve diagnosis and images
treatment planning in several fields of dental science [9 - 11]. 3D Surface Rendering (Fig. 4)

Fig. (1). Sagittal.

Fig. (2). Coronal.

Use of 3D Imaging for Treatment The Open Dentistry Journal, 2019, Volume 13 139

Fig. (3). Axial.

Fig. (4). 3D Surface Rendering.

Both 2D and 3D images have been obtained in files [1] Mesiodistal position of the canine
DICOM and CBWorks software (CyberMed, Seoul, Corea) has [2] Vestibular-palatal position of the canine
been used for segmentation procedure. Subsequently, due to [3] Vertical position of the canine
the subtraction techniques, hard and soft tissues maintaining [4] Root resorption
only maxillary teeth have been removed. In order to avoid [5] Treatment plan with extractions
possible bias related to the operator, only one expert operator [6] Treatment plan without extractions
performed maxillary teeth segmentation. 3D images of [7] Orthodontic approach (Vestibular or Palatal)
impacted cuspids have been evaluated on the sagittal, frontal [8] Direction of initial orthodontic traction vector
and axial planes. Impacted canines images have been selected (Vestibular-Palatal or Mesiodistal)
by an independent operator that used a randomization system [9] Direction of secondary orthodontic traction vector
(www.randomizer.org). Image analysis has been performed by (Vestibular-Palatal or Mesiodistal)
14 expert orthodontists’ which implemented a treatment [10] Possibility of spontaneous eruption
planning of four maxillary impacted canines of similar clinical [11] Level of root development and spontaneous eruption
complexity. Each orthodontist provide a specific form in order [12] Possible root resorption of the adjacent teeth
to acquire personal data of the patient and elaborate a treatment [13] Need more diagnostic investigations
plan for the correction of canine impaction with a specific
indication about surgical approach (Palatal-Vestibular) and For both sub-group study, if the evaluations at V1 and V2
orthodontic biomechanics. The study group has been divided were concordant, a score of 1 was assigned if it was not
into two subgroups: concordant, a score of 0 was attributed. The time necessary for
each clinician to perform the treatment plan at V1 has been
evaluated. All the teeth have been evaluated in a single session.
GROUP 1 → Consisting of seven orthodontists that
The assignment of the orthodontist to the two subgroups has
have been evaluated at first the bi-dimensional images
been carried out with a randomization system (www.
(V1) and then the 3D rendering (V2)
randomizer.org). The time necessary to complete the validated
GROUP 2 → Consisting of seven orthodontists that
form used in the study ranged between 1,5 and 2,5 hours.
have been evaluated at first the 3D rendering images
(V1) and then the bi-dimensional ones (V2) 2.1. Power Analysis of the Sample and Statistical Analysis
Evaluation form filled out by the orthodontist both at V1 In order to evaluate the correct number of patients to enroll
and at V2, requires: in the present study, a power test has been carried out on a
140 The Open Dentistry Journal, 2019, Volume 13 Portelli et al.

preliminary enrolled small sample. The sample size calculation rendering images observation, and also the choice of initial
was performed considering the following outcome: Mesiodistal recovery vector has been corrected. In Group 2 study, when 3D
canine position. The calculation was executed considering the rendering images have been observed before the bidimensional
following data: Group 1 (17% of concordance) and group 2 ones, the level of concordance between the evaluation at V1
(75% of concordance). The power analysis calculation was and V2 was significantly higher than in Group 1 study. In this
performed placing 1-β at 0.8 and Alfa at 0.05. Median value group, ten score concordance modifications between V1 and
and standard deviation of the parameter T have been calculated V2 have been registered, instead in the Group 2 study, only
for both group, and they were compared with a T-Student Test. four changes have been made. The variables of agreement to
A count of the scores 0 and 1 inside the two study subgroups the survey form in the two study groups have been graphically
has been performed and then has been compared with a T- reported in Fig. (5).
Student Test. The level of significance was with α<0.05. Data
has been analyzed with StatView (version 5, SAS Institute, A significant difference has been registered about the time
Cary, NC) in order to evaluate the difference between bi- necessary to perform treatment planning; in the Group 2 study,
dimensional images and 3D renderings. the meantime registered was lower than in group 1 study (12 ±
3.32 min vs 23 ± 2.53 min, p < 0.05).
3. RESULTS
4.. DISCUSSION
All orthodontist completed the survey and the observation,
and used it for this study. The analysis of the survey filled out In this study, the clinical relevance of 3D CBCT images
in two subgroups at V1 and V2 revealed a difference in the compared to the 2D ones has been evaluated for the diagnosis
mesiodistal position of the impacted canines with a level of and treatment planning of impacted canines. CBCT allows 3D
disconcordance equal to 75% (p > 0.05). This finding was reconstruction on craniomaxillofacial district and provides the
higher for the vestibular-palatal position evaluation with a level dynamic images. Unlike, conventional radiology produces only
of disconcordance equal to 84% (p > 0.05). Regarding the a static planar image [14 - 16]. CBCT images can be formatted
vertical position of the canine, the concordance was in the 50% in order to obtain traditional radiographic projection such as
of cases; for root resorption instead, the concordance was at a ortopano, latero-lateral and posterio-anterior projections.
level of 44%. In this case, image quality (2D vs 3D) had CBCT prefers traditional Computed Tomography for the lower
significantly influenced the evaluation (p < 0.0001). The costs and the reduced radiological exposition [17 - 21]. The
significant discrepancy was found in treatment planning, results of the present study show difference, although not all
including the possibility of repositioning or extraction, and in significant, between the two study groups for the observations
cases of tooth recovery, about the choice of initial vector. In performed at V1 and V2, above all for the vestibular-paltal and
27% of cases, treatment planning has been modified after 3D mesiodistal position of the impacted teeth.

90

80
Agree

70
Disagree
60

50

40

30

20

10

0 Mes-Dist Vest-Lin Vertical Root Res Treat Plan

Fig. (5). Variables of agreement to the survey form.

Use of 3D Imaging for Treatment The Open Dentistry Journal, 2019, Volume 13 141

A significant difference has been registered for treatment CONSENT FOR PUBLICATION
planning. In 27% of cases, treatment planning has been Written informed consent for the participation was
modified after 3D surface rendering observation because 3D obtained from each participant.
images provide more direct information than 2D CBCT images
[22]. In cases of root resorption of adjacent teeth, 3D surface CONFLICT OF INTEREST
rendering is however affected by operator subjectivity. The
limits of the present study are: The authors declare no conflict of interest, financial or
otherwise.

Clinicians evaluated the same level of complexity ACKNOWLEDGEMENTS

cases; results may be different in cases of different
Declared none.
clinical complexity
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