Rom J Morphol Embryol 2014, 55(3 Suppl):1197–1202

RJME
CASE REPORT Romanian Journal of
Morphology & Embryology
http://www.rjme.ro/

A rare case of canine anomaly – a possible algorithm for

treating it
LIGIA VAIDA1), BIANCA IOANA TODOR1), CLAUDIA COREGA2), MIHAELA BĂCIUŢ3), GRIGORE BĂCIUŢ4)
1)
Department of Dentistry, Faculty of Medicine and Pharmacy, University of Oradea, Romania
2)
Department of Orthodontics, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3)
Department of Implantology and Maxillofacial Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca,
Romania
4)
Department of Oral and Maxillofacial Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Abstract
Canine transmigration is a very rare dental anomaly in which an unerupted mandibular canine migrates, crossing the mandibular midline.
This unusual condition is most often diagnosed by chance during a routine X-ray examination. The most common clinical signs announcing
the presence of this anomaly are over-retention of the deciduous canine and the absence of permanent canine from the dental arch after its
physiological period of eruption. In this paper, we present a clinical case, 10-year-old boy, who was diagnosed with mandibular right canine
transmigration at three years after the start of orthodontic treatment, during which we were expecting the eruption of mandibular canines.
The orthopantomograph revealed the mandibular right canine to be in a horizontal position under the apices of the incisors – type 2
transmigration pattern classified by Mupparapu (2002). Based on cone-beam computer tomography examination, we recommended a surgical
exposure of the canine and orthodontic alignment. Due to the risk of root resorption of the mandibular right lateral incisor during orthodontic
movement phase of canine transmigrated to the dental arch, we decided to align the mandibular right canine in a transposition, between the
two mandibular right incisors. Then we resorted to adapting the mandibular right lateral incisor coronary morphology to simulate a canine
and also to reshaping the canine coronary morphology to resemble a lateral incisor. This therapeutic approach allowed us to restore
morphologically and functionally the mandibular dento-alveolar arch, preserving the entire dental system.
Keywords: transmigrated canine, orthodontic treatment, canine coronary morphology, laterals incisor coronary morphology.

 Introduction supernumerary teeth, cysts and tumors, and an excessive

According to the literature, canine transmigration is a
very rare and unusual dental anomaly [1–3]. Joshi (2001)
defined transmigration as the migration of a tooth across
the jaw midline without the influence of any pathological
entity [4]. Tarsitano et al. (1971) suggested that trans-
migration is a phenomenon in which an unerupted mandi-
bular canine migrates, crossing the mandibular midline
[5]. According to Javid (1985), transmigration should be
considered when half of the length of the crown crosses
the midline [1].
The occurrence of transmigration of mandibular canines
varies from 0.14% to 0.31% [6, 7]. While canine impaction
affects the maxilla much more frequently than the mandible
canine, transmigration is found more frequently in the
mandible. Also, the unilateral canine transmigration is
more common than the bilateral canine transmigration,
especially at the mandible [1, 4, 6–8]. Aktan et al. (2010)
reported incidence of maxillary canine transmigration
as 0.14% and the incidence of mandibular canine trans-
migration as 0.34%, with the right side affected more
often than the left side in both jaws [6]. There is clinical
evidence where canine transmigration may be associated
with transmigration of other teeth [9, 10].
The mechanism that causes this canine transmigration
is still not clear [11]. However, there are some assumptions
considering the following etiological factors: retention
or premature loss of primary teeth, crowding, spacing,
crown length of the mandibular canine [8, 12]. In the
literature, there is no clear evidence to prove that the
canine transmigration could be congenitally inherited.
In 2002, Mupparapu used five criteria to classify the
transmigrated mandibular canines depending on its path
of deviation. Type 1: Positioned mesioangularly across the
midline within the jaw bone, labial or lingual to anterior
teeth, and the crown portion of the tooth crossing the
midline (45.6%). Type 2: Horizontally impacted near the
inferior border of the mandible below the apices of the
incisors (20%). Type 3: Erupting either mesial or distal to
the opposite canine (14%). Type 4: Horizontally impacted
near the inferior border of the mandible below the apices of
either premolars or molars on the opposite side (17%).
Type 5: Positioned vertically in the midline (the long
axis of the tooth crossing the midline) irrespective of
eruption status (1.5%) [13].
This paper aims at reporting a case of transmigration
of mandibular canine, at discussing the importance of
early diagnosis and treatment planning and at presenting
our option for canine transmigration treatment in order
to restore the mandibular dento-alveolar arch, morpho-
logically and functionally.
 Patient, Methods and Results
This paper presents a clinical case diagnosed with this
rare anomaly, canine transmigration, that we approached

ISSN (print) 1220–0522 ISSN (on-line) 2066–8279

1198 Ligia Vaida et al.
by surgical exposure and orthodontic treatment. Unlike
other cases of canine transmigration presented in the
literature, in this case the transmigration of canine
occurred during the period when the patient was under
orthodontic treatment.
The patient, a 10-year-old boy, presented to our clinic
in 2007 requiring treatment of dental crowding. During
the clinical examination, we noticed the presence of mixed
dentition, a delayed dentition, permanent teeth being only
the first molars and incisors on both dental arches. The
medical examination and treatment was conducted with
the written informed consent of his mother who was also
instructed regarding our intention to include this case in
a scientific paper.
First radiological examination
Upon radiological examination (orthopantomograph
– Figure 1), we found the presence of a mixed dentition,
deciduous teeth presenting complicated decays and large
coronary destructions. Intramaxillary, one could see the
presence of all permanent teeth buds. In that period, we
did not associate the slight mesial inclination of the
mandibular right canine bud with a possible pathological
evolution.
Figure 1 – Orthopantomograph from the beginning
of the orthodontic treatment: 10-year-old patient with
mixed dentition.
Orthodontic treatment
We started the orthodontic treatment of the maxillary
dental arch with a removable appliance. In the mandibular
dental arch, we found the presence of tooth eruption
disorders with persistent deciduous canines after the
eruption of second premolars (Figure 2).
After one year of treatment, during which the lateral
incisors and premolars erupted in maxillary dental arch
(Figure 3), we continued upper arch treatment with a fixed
appliance without requiring the patient a new orthopan-
tomograph for avoiding additional radiation.
Subsequently, we observed in the mandibular dental
arch delayed left permanent canine eruption while the
right deciduous canine continued to persist. Then, we
decided to extract the deciduous mandibular right
canine (Figure 4) and to start orthodontic treatment with
fixed appliance in the mandibular dental arch.
Second image examination
We asked the patient to take a new radiological
investtigation after three years from the beginning of the
treatment. Panoramic radiograph revealed the mandibular
right canine to be in a horizontal position under the apices
of the incisors – type 2 transmigration pattern classified
by Mupparapu (2002) (Figure 5) [13]. This transmigrated
canine was radiographically seen to be surrounded by a
cystic lesion.
Surgical exposure and orthodontic alignment
of the canine
As a result of a began cone-beam computer tomo-
graphy (CBCT) examination (Figure 6), that revealed the
presence of a dentiger cyst surrounding the transmigrated
canine and its relationship with the neighboring anatomical
structures, we decided to recommend a surgical inter-
vention, in order to perform a canine exposure and
bonding of attachment to allow subsequent orthodontic
traction of the canine (Figure 7).
The canine distalization and uprighting were possible
only using skeletal anchorage represented of mini-implant,
otherwise there was a high risk to damage other teeth
from the dental arch (Figure 8).
During orthodontic movement phase of canine trans-
migrated to the dental arch, we reassessed, using CBCT
investigation, the canine position and its relationship with
incisors roots. We noticed the risk of root resorption of
the mandibular right lateral incisor. This observation led
us to the decision to distalize the mandibular right lateral
incisor in contact with the first premolar, by using ortho-
dontic forces, and to align the mandibular right canine in
a transposition, between mandibular right lateral incisor
and mandibular right central incisor (Figure 9).
After aligning the mandibular right canine in the
dental arch between the two incisors, we found a canine
gingival retraction. CBCT revealed the lack of vestibular
bone support of the canine. These findings led us to the
need for intervention of canine periodontal surgery after
removing the orthodontic appliance.
Periodontal surgery procedure
Based on clinical examination corroborated with para-
clinical examination (CBCT), it was noticed gingival
retraction at canine, Class 3 Miller, as well as bone loss
at buccal alveolar ridge of the respective tooth. Using a
bone collecting single use tool, it was taken autologous
bone at the level of chin using the scraping technique.
The approximately one square centimeter bone sample
was used to cover the bone deficiency at the alveolar
vestibular level of canine (Figure 10). Therewith were done
horizontal excisions of ties scars and lower labial frenulum
in order to avoid the possible subsequent tractions of the
flap.
Morphological and functional restoration of
the dental arch
Morphological and functional restoration of the
mandibular dental arch at the end of the orthodontic
treatment, according to this complete therapeutic trans-
position, involved adjusting the lateral incisor crown in
order to give it the morphological aspect of a canine and
also reshaping the canine coronary morphology to resemble
a lateral incisor. For this purpose, we focused on the
application of a veneer on the lateral incisor and composite
angular addition on the canine crown (Figure 11).
 A rare case of canine anomaly – a possible algorithm for treating it 1199

Figure 2 – Mandibular dental arch: Figure 3 – Intraoral aspect before treatment with orthodontic fixed appliance:
tooth eruption disorders (eruption of (a) Maxillary dental arch – lack of space for permanent canines’ eruption;
second premolar before canines’ (b) Frontal occlusion.
eruption).

Figure 4 – Intraoral aspect after applying

the maxillary fixed appliance: (a) Ortho-
dontic treatment phase in the upper dental
arch; (b) Mandibular dental arch after
extraction of lower right deciduous canine.
Note the delayed eruption of lower left
canine in a severe disto-vestibular rotation.

Figure 5 – (a and b) Ortho-

pantomograph after three
years from the beginning
of the treatment shows the
lower right canine trans-
migration (red arrows)
in a horizontal position
under the apices of
the incisors.

Figure 6 – (a–c) CBCT, the axial sections showing the anatomical relationship of transmigrated canine with the lower
incisors roots.

Figure 7 – Intraoperative and postoperative aspect: (a) The osseous cavity after Figure 8 – Orthodontic treatment
the enucleation of the dentiger cyst; (b) The first system of canine orthodontic phase, distalization of lateral incisor
traction to the dental arch. and orthodontic retraction of the
transmigrated canine using a mini-
implant.
1200 Ligia Vaida et al.

Figure 9 – Orthodontic treatment phase:

(a) Mandibular dental arch with lower
right canine aligned between lower
lateral incisor and central incisor;
(b) Frontal occlusion during orthodontic
treatment.

Figure 10 – Periodontal surgery: intraoperative

images. Flap coronary moved surgery at 4.3–3.3
level followed by bone augmentation.

Figure 11 – Intraoral aspect at the end of the treatment: (a) Occlusion of the
right half profile; (b) Frontal occlusion; (c) Occlusion of the left half profile;
(d) Mandibular dental arch – the right canine crown was reshaped to
simulate a lateral incisor and the right lateral incisor crown
was also reshaped to simulate a canine.

 Discussion treatment for transmigrated canines, rather than making

Migration of a tooth across the midline is a rare
anomaly. However, at least 157 cases of mandibular canine
transmigration were already published 10 years ago [3,
14, 15]. Until 2011, 196 cases of mandibular canine trans-
migration have been reported [16]. This anomaly creates
surgical, orthodontic, interceptive and restorative problems.
The most transmigrated canines are asymptomatic and
therefore the patients are not aware of this condition.
Most of these transmigrated canines are usually detected
during routine radiological examinations. In order to
confirm the diagnosis, the following types of radiographs
may be used: dental pantomographs, occlusal, periapical,
lateral cephalometric and three-dimensional investigations
(cone-beam computer tomography is likely to be preferred
nowadays). However, there are some clinical signs of
transmigration that have been reported, such as: over-
retention of the deciduous canine, proclination of the
mandibular anterior teeth, an enlarged symphyseal area,
and chronic infection with fistulization [6, 11].
In our study, three factors might possibly cause the
transmigration: over-retention of the deciduous mandibular
right canine, mesial inclination of the canine bud and the
presence of the dentigerous cyst.
There are several treatment options proposed for
unerupted canines:
(1) Surgical removal appears to be the most favorable
effort to bring the tooth to its original place. This is
especially indicated when the mandibular teeth are
crowded and require therapeutic extractions to correct
the incisor crowding [11].
(2) Surgical exposure and orthodontic alignment. Few
of the orthodontists succeeded successfully orthodontic
alignment of transmigrated canines on the dental arch [17].
Wertz used orthodontic treatment to bring three labial
transmigrated canines into position [18]. Kumar et al.
(2012) reported success in orthodontic treatment of a
transmigrated lower left canine, which was located with
its crown below the apices of the right central incisor
[19]. Camilleri and Scerri (2003) suggested that if the
crown of such a tooth migrates past the opposite incisor
area or if the apex migrated past the apex of the adjacent
lateral incisor, it might be mechanically impossible to
bring it into place [11].
(3) Transplantation. If the mandibular teeth are not
crowded, incisors are in a normal position and the space
for the transmigrated canine is sufficient, transplantation
may be a choice.
(4) Observation (radiographic monitoring). Trans-
migrated canines can be left in place and kept under
observation until the appearance of the first symptoms
such as the existence of pressure, roots resorption of
the adjacent teeth, periodontal disturbances, prosthetic
 A rare case of canine anomaly – a possible algorithm for treating it
problems, malposition of the adjacent teeth, neuralgic
symptoms, a progressive worsening of the position of the
canine or suggestion of cystic change. These symptoms
represent indications for surgical interventions. In these
situations, a series of successive radiographs should be
taken periodically [12, 17, 20]. Most authors stated that
transmigrated canines usually have to be removed rather
than a heroic effort to reposition them to their original
place [20–22].
Auluck et al. (2006) reported four cases of mandibular
canine transmigration, all detected after the age of 20-
year-old, of whom three symptomatic and one asympto-
matic and emphasized the importance of early diagnosis
and early treatment to avoid complications [23].
In the clinical case presented by us, mandibular canine
transmigration occurred in a period of three years.
Despite the fact that there was a mesial inclination of
mandibular right canine bud with 390 (Figure 12), we did
not suspect it then as a possible pathological evolution,
so that we did not propose to follow the case from this
point of view. The left mandibular permanent canine
that delayed erupting led us to consider the existence of
disturbances in the eruption sequence of the mandibular
canines and, therefore, we did not ask the patient to take
a new orthopantomography earlier than it could show
the tendency to transmigration. Our study highlights
the importance of clinical and radiological following of
mandibular canines’ eruption especially when there is a
more pronounced mesial tilt.
Figure 12 – The axial
inclination of the
mandibular right
canine bud to mid-
sagittal plane, α=390,
at the beginning of
the orthodontic
treatment (patient
aged 10 years).
Because the canine migrated to the contralateral hemi
arch, it was not possible to align it in its original position
on the dental arch. Nevertheless, we succeeded to integrate
it between the two mandibular right incisors. However,
an acceptable outcome was gained that allowed us to
obtain morphological and functional restoration of the
mandibular dental arch with the conservation of the entire
dental system and to achieve a functional occlusion to
ensure optimum evolution of stomatognathic system.
According to Stafne (1963), the greatest amount of
canine intraosseous movement takes place prior to
completion of tooth root development – between the ages
of 11- and 14-year-old [24]. Peck (1998) suggested that
the intraosseous migration of a canine apparently starts
earlier, during the early mixed dentition stage and may
last many years [25]. If the diagnosis had been made even
later, the transmigrated canine probably would have
continued to move in the contralateral hemi arch to the
premolar and molar region. Joshi (2001) suggested that
the stage of transmigration will depend on the time of
diagnosis [4]. Thus, Auluck et al. (2006) and Aktan
et al. (2008) reported two cases of extreme transmigrated
canines, where the canines were lying horizontally under
1201
the second molar and third molar on the opposite side
[23, 26].
In our study, transmigrated canine orthodontic treat-
ment would not have been possible without holding prior
information provided by CBCT, a radiological investi-
gation that revolutionized the bone analysis and treat-
ment planning. The information revealed by CBCT is
needed for a lot of purposes, such as: assessment of bone
support; examination of teeth and facial structures to start
orthodontic treatment; examination of the relationship
between the impacted teeth and the neighboring anato-
mical structures; diagnosis of cysts, tumors or infections
of the teeth and jaw bones [27, 28]. We requested a new
CBCT investigation during orthodontic retraction canine
phase to assess its position and its relationship with
incisors’ roots.
Also, transmigrated canine orthodontic movement
toward dental arch would have been extremely difficult,
if not impossible, without the use of skeletal anchorage
represented by mini-implant. Mini-implants are an excellent
alternative to conventional orthodontic anchorage systems
such as intraoral dental anchoring units, which run the
risk of severely damaging the teeth. Other advantages
include their relatively small size, which results in minimal
anatomical limitations, user-friendly protocol, immediate
loading potential, adaptability to biomechanics in effecting
orthodontic and orthopedic forces, high success rate, low
cost and, most importantly, patient acceptability. The
use of orthodontic mini-implant simplified the treatment
plan and allowed us a maximum conservation of tooth
structures [29–31].
With respect to the treatment of these canines, inter-
ceptive treatment should be carried out, although it is
extremely difficult, if not impossible, to predict the
appearance of this anomaly. For Joshi (2001), predicting
the appearance of this anomaly depends on the inclination
that the canine tooth germ presents. If the angle formed
by the mid-sagittal plane and unerupted canine is less than
300, transmigration is unlikely. If the angle is between 300
and 500 unerupted canine may tend to cross the midline.
When the angle exceeds 500, crossing the midline becomes
a rule [4, 32].
Sharma and Nagpal (2011) suggested that angulation
of long axis of unerupted canine with mid-sagittal plane
should always be evaluated in mixed dentition period.
An early and timely intervention would lead to better
management of the transmigrated canine and hence to
avoiding the potential complications associated with
transmigrated canine [16].
Vichi and Franchi [33] suggested that an 8- to 9-
year-old patient with an excessive mesial inclination of
the unerupted mandibular permanent canine germ should
be kept under observation with periodical panoramic
radiographic examinations. If the position of the unerupted
mandibular canine is observed to tilt mesially progress-
sively, interceptive measures should be taken. The
preventive and interceptive treatment should include
extraction of the retained deciduous canine and surgical
exposure of the transmigrated canine followed by ortho-
dontic treatment [20, 33]. According to this observation,
our study emphasizes the importance of early diagnosis
to correct this abnormality before the tooth migrates too
far from its original place.
1202 Ligia Vaida et al.
 Conclusions
In the presentation of this case report, we intended to
highlight the importance of a rigorous analysis of the
position and mesial inclination of the lower canines’ buds
in a routine radiological examination, such as orthopan-
tomograph, and also the importance of proper investigation
of persistent deciduous canines on dental arches. The
transmigrated canine treatment success is conditioned
by the early and correct diagnosis and an appropriate
treatment planning, which often requires an interdisci-
plinary approach.
Author contribution
All the authors equally contributed to the drawing up
of the present paper.
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