A Becker The etiology of palatal

I Qillis
N ShJJack
displacement of maxillary
.
canines

Authors' affiliations: Abstract: Palatal displacement of maxillary canines occurs

A. B~cker, /. (Jrllrs, Department of Orthodon-
tics, Hd.,rew L'nivcrsity-Hadassah School of
Dental ~ledicine, Jerusalem, Israel
:-\. Sht>uck, D~partment of Orthodontics, The
~Iaurice and Gabriella GolJschleger School of
Dental ~!eJicine, l'niversity of Tel Aviv,
Israel
Correspondence to:
A. Bc,·kcr
Department of OrthoJontics
Hehrcw lJniversity-HaJassah School of Dental
Medicine, founded hy the Alpha Omega Fra-
ternity
Jerusalem
Israel
Fax: + 9i2 2 5635415
E-mail: aJrianl-o®cc.huji.ac.il
with greater frequency in patients with certain genetically de-
termined abnormalities. including peg-shaped, reduced and
congenitally missing lateral incisors. One view is that the ca-
nine aberration is similarly genetically determined, while a sec-
ond view is that the genetically determined anomalies of the
lateral incisors provide an environment that deprives the erupt-
ing canine of its normal guidance. Earlier work has shown that
canine displacement occurs more frequently in patients with
peg-shaped or reduced lateral incisors than in those with
missing lateral incisors, which has been explained away by
variability due to gene penetrance and individual thresholds. A
group of individuals was examined, in whom a missing lateral
incisor on one side, a peg-shaped or reduced lateral incisor
on the other, and a palatal canine were present in the same
individual, in order to eliminate gene penetrance and individual
thresholds as factors. A distinct preference for the canine
anomaly to occur on the side of the peg-shaped or reduced
lateral incisor was found. This was considered to provide evi-
dence in support of the existence of non-genetic, environmen-
tal factors in the causation of palatal canine displacement.

Key words: environmental causes; genetic determinants;

palatally displaced canines; peg laterals

Introduction

Information available from population studies indicates

that the prevalence of palatally impacted canines is be-
Dates:
AccerteJ !! Fel--ruan· 1999
tween 0.92 and 1.8% (1- 3). Impactions are two to three
To cite this article: times more common in females than in males (1, 4-6) and
Clm. Orrh. Re.<. 2, 1999; 62-66 8% of these individuals are affected bilaterally (7). A
Becker A, Gillis I, Shrack N:
Thr l'tiolo~y of ralaral J!Srlacrm<·nr of maxillary ca-
much higher incidence of palatally displaced canines oc-
nine§ curs adjacent to anomalous upper lateral incisors (2, 4, 8).
The reason for this association is under dispute. Peck et
ISSN I 397->927 a!. (9) support a genetic theory according to which a

number of genetically associated phenomena frequently
appear concomitantly, without a cause-and-effect relation-
ship. These phenomena include anomalous (small or peg-
shaped) or missing lateral incisors, small teeth, partial
anodontia, transposition of maxillary canine and first
bicuspid or lateral incisor, infraoccluded primary molars,
partially impacted first permanent molars (10, 11), and in
addition, palatally displaced canines. In contrast, Becker
et a!. (4) have suggested a guidance theory, hypothesizing
that genetically determined small or peg-shaped lateral
incisors provide an environmental cause for palatal canine
displacement.
Broadbent and Dewel (12, 13) described the physiologic
eruption of the permanent dentition in which the nor-
mally developing canine begins its early eruptive move-
ment in an inferiorly directed vector until it comes into
close relation with the bucco-distal aspect of the root of
the normal lateral incisor; which guides it to its final and
normal erupted position. Supporting the hypothesis origi-
nally proposed by the Jerusalem group (4), Bishara stated
that the presence of the lateral incisor root of the right
length, formed at the right time, are important variables
needed to guide the mesially erupting canine in a more
favorable distal and incisal direction (7).
The guidance theory proposes that a missing or anoma-
lous lateral incisor (having a later-developing root) creates
an environment, which lacks the capability to guide the
eruption of the canine. The canine is thus not prevented
from moving in a palatal or a palatal-and-downward direc-
tion. A small minority move palatally only and become
horizontally impacted. Those that move further down
improve their bucca-lingual orientation by the influence
of the inferiorly narrowing alveolar process. However, if a
late-developing lateral incisor is present, further sponta-
neous correction comes to an abrupt standstill, trapped
on the palatal side of this lateral incisor. The guidance
theory suggests that agenesis of the lateral incisor will
allow the canine to continue its corrective downward path
until it finally erupts into a more normal bucco-lingual
position.
That missing and peg-shaped lateral incisors are geneti-
cally determined is not the subject of dispute. The two are
intimately related, being produced by a single genetic
factor (14, 15), with the missing tooth representing the
severer expression of the phenomenon.
According to our earlier work (4), there is a greater
prevalence of palatal displacement of maxillary canines
adjacent to a small or peg-shaped lateral incisor than may
Be("ker et al. Disrla('em.:nr l_)f maxlil.In· ('anmes
be seen on the side of a missing lateral incisor. The
guidance theory provides a cogent explanation for the
discrepancy. However, criticism has been lewled at this
earlier study, since all the cases were of unilateral dis-
placed canines, with the unaffected sides being used as
controls. Peck et a!. (16) objected to the use of the
unaffected side within the same individual as a control.
They believed that, '... for dental abnormalities under
genetic control, variations in gene penetrance and individ-
ual thresholds can easily explain the variable phenotypic
expression of an abnormality or related abnormalities'.
The present study was initiated to determine the fre-
quency of palatal displacement of the canines adjacent to
missing lateral incisors versus those adjacent to small or
peg-shaped lateral incisors, in the same individual. Since
the right and left sides of the same individual have the
identical genetic pattern, it is to be expected that such a
study should provide information on the etiology of
palatal canine displacement that may overcome the objec-
tions of Peck et a!. (16) and thus lend support to one of
these theories over the other ( 16, 17).
The working hypothesis was as follows:
If the phenomenon of palatal displacement of the maxil-
lary canine is completely under genetic influence, as pro-
posed by Peck et al. (9), then it is to be expected either
that canine displacement should occur with equal fre-
quency on both sides or that it should occur more
frequently on the side of the missing lateral incisor than
on the side with the peg-shaped or small lateral incisor,
since a missing tooth represents the severer expression of
the condition. Gene penetrance and individual thresholds
within the same individual are the same for right and left
sides. Should there be a greater phenotypic expression of
one genetic abnormality (such as a missing lateral incisor)
on one side, it is likely to be linked to a similarly greater
phenotypic expression of a related genetic abnormality
(the palatal canine - if it is completely under genetic
influence) on that same side.
Materials and methods
The records of over 12 000 consecutive orthodontic cases
were examined, gathered from four private orthodontic
practices in Jerusalem, Herzlia, and Netanya and from the
Orthodontic Departments of the Universities of Jerusalem
and Tel Aviv. From these cases, an experimental sample
was put together, comprising all cases exhibiting the fol-
lowing criteria:
Clm O...h ll<• Z. 199<1 6~-t.c\ I 63
Becker et al. Displacement of maxillary canines
1. a unilaterally missing maxillary lateral incisor,
2. a small (4) or peg-shaped (4) lateral incisor on the
contralateral side,
3. a unilateral palatally displaced maxillary canine.
The side on which the palatally displaced canine occurred,
whether this was on the missing or on the peg-shaped
side, was recorded. These results were then subjected to a
two-tailed binomial test.
Results
The search in approximately 12 000 orthodontic cases
yielded 19 patients with each of the above criteria. The
palatal canine was associated with the missing lateral
incisor in 3 cases (16%), while it was found to be adjacent
to the reduced or peg-shaped lateral incisor in 16 cases
(84%).
Discussion
The incidence of missing lateral incisors, of peg-shaped
lateral incisors, and of palatal canines in most of the
populations studied has been found to be between 1 and
2% for each of the phenomena and 4% for lateral incisors
of reduced mesio-distal width (2). Thus, finding sufficient
cases in which all three phenomena are present in a single
individual requires searching through a very large or-
thodontic population, as was seen here.
The frequency with which a palatally displaced canine
occurred on the side of the anomalous lateral incisor was
5.3 times more than when it was related to a missing
lateral incisor. This was found to be significant at the
0.04% level (p = 0.0004) using a two-tailed binomial test.
These results clearly show the working hypothesis to be
unfounded. Not only was the impacted canine not found
in equal distribution on the two sides, but there was also
a strong bias for the palatally displaced maxillary canine
to be found on the side of the anomalous lateral incisor,
which is the weaker phenotypic expression of the genetic
abnormality.
The guidance theory, as described earlier (4) and as
summarized in a recent text (18), fully recognizes that
genetic factors are at work in the siting of the developing
tooth bud of a maxillary canine and that, in some rela-
tively uncommon circumstances, this siting may be abnor-
64 I a ... Ortk R-. z. 1999/62. 66
mal, such as in a canine-lateral incisor or canine-first
premolar transposition. The term 'primary tooth germ
displacement' has been used to describe these hereditary
conditions and the present senior author has made a
distinction between these and the more common displace-
ments. From the evidence presented here, it seems appar-
ent that a local environmental factor or factors are indeed
present and directly involved in the causation of the
phenomenon. On the basis of this study, the hypothesis
that canine displacement is fully under genetic influence,
as proposed by Peck et al. (9), would appear to be flawed.
The guidance theory offers a cogent alternative explana-
tion that is supported by the results of this study.
Abstrakt
Palatinal verlagerte Eckzahne treten haufiger bai patienten mit
gcnetisch determinierten Zahnanomalien wie beispielsweise stiftfi)rmi-
gcn, mikrodenten oder nichtangelegten seitlichen Scheindezahnen auf.
Einc Erklarung hierfi.ir ist, JaB Eckzahnverlagcrungcn genetisch anlich
detcrminiert sind, nach c.-iner anderen schaffen Anomalien der
seitlichen Scheindezahne ein lokales Umfeld, das durchbrechendc Eck-
zahne ihrer normalen Fi.ihrung beraubt. Fri.ihere Untersuchungen
zeigten, daB Eckzahnverlagerungen haufiger bei Patienten mit fehlenden
seitlichen Scheindezahnen. Dieses Phanomen wurde mit Schwankungen
Jer genetischen Penetranz und des individuellenSchwellenwertes
erklart. Hier wurden Eckzahnretentionen in einer Gruppe von lndi-
viduen untersucht, die auf Jer einene Seite Stiftformige/mikrodonte
laterale lnsizivi und auf Jer anderen Unterzahl aufwiesen, so daB eine
unterschiedliche Genpenetranz und ein verschiedener individueller
Scheinwellenwert ausgeschlossen werden konten. Es fand sich eine
deutliche Haufung von Eckzahnretentionen auf der Seite, wo stift-
formige oder mikrodonte seitliche Schneidezahne aufgetreten waren.
Diese Tatsache untersti.itzt die Hypothese, daB nicht genetische, son-
Jem Umweltfaktoren die Urache fi.ir Eckzahnverlagerungen sind.
Resumen
El desplazamiento palatal de caninos maxilares, ocurre con mayor fre-
cuencia en pacientes con abnormalidades determinadas geneticamente,
incluyendo 'peg-shaped', incisores laterales reducidos y congenitamente
ausentes. Una opinion considera que Ia aberraci6n canina es similar-
mente determinada geneticamente. AI mismo tiempo, una segunda
opinion, considera que las anomalias de los incisores laterales determi-
nadas geneticamente, proveen un ambiente que depriva el creciente
canino de su curso normal. Trabajos anteriores han demostrado que
el desplazamiento ocurrc con mayor frccuencia en pacientes con 'peg-
shaped' o incisores laterales reducidos, que en aquellos con ausencias
de incisores laterales, que se ha tratado de explicarse como resultado
de variabilidades Jebido a Ia penetracibn del gene en umbrales indi-
viduales. Un grupo de individuos fueron examinados, en los cuales Ia
ausencia de un incisor lateral en un lado, un 'peg' o incisor lateral
reducido en el otro, y un canino palatal, estuvo presente en el mismo
individuo, y asi poder eliminar como factores las penetracioncs del
gene y umbrales individuales. Una preferencla peculiar para Ia anoma-
lia can ina, es que ocurra en un laJo del 'peg-shaped' y lateral reJu- Structured Abstract
cido. Esto fue considerado para pro\"eer e\"iJencia en apnyo de Ia
existencia Je factores ambientales no-gcneticos, en Ia causa del de- Awhor.< ~ Becker A. t~illis I. Shpack ~-
spla:amiento palatal del canino. 0/>jccriws - To test the hypothesis that palatal displa.:ement of tlw
maxillary canine is completely under genetic influence.
Dc.<ign - A randomi:ed controlled design studied cases affened hy
~~ a se\"en• expression of lateral incisor anomaly on ont• side and hy
milder expression of the same anomalY on the other. Comparison
~~~~~D-~E~~.~W~~~~~.
of frequency of occurrence of unilateral palatall\" displact·d .:aninc•
~~~. ~~~m~~u~¢•~•~tt~~ measured in ea.:h. Each side acted as "''ntrol for the nthc·r within
the same individual.
~~~?~~-~~-~~~Gh¢. -?~ Sc!!ini! and Sampk l'of>a<latwn ~ Tht• Dt·partments of Orthodontic"s
·of the Uni\"ersities of Jerusalem and Tel An\" and in pri\"ate prac-
~m~~~~E~~-U~¢-~tt~~~a
tke. From approximately I 2(l(\1 c·onst•cutin·ly treated patients, all
.tt -c ~~ ¢ t ~ ¢ 'b ~ ~ ~ tJ • -'t ~ -15 "t" BIJ ~ those exhil:-iting an anterior maxilla with a missin~ lateral incisor
on one sid~. a peg-shaped or redu.:eJ lateral incisor on th~ other.
Am~. ~w~~~~¢-~tt~••~AAm and a palatally Jisplaced canine (n = 19).
~~~~~G~~~AAlliM·~-~c~¢'b Outcome ll.icasurc ~ 1\lissin..: lateral incisors. pel!-shap..-,1. anJ re-
duced lateral indsors (all genetkally dett·rmineJ characters) ha\"l'
~"t"~¢. WM~~R"t"~. ~W·~~~~ been shqwn to be associated with palatal displacement of the ca-
nine. The canine displacement is presumt•J hy some authorities to
tzo ~ t.: J!\. J:: tJ 'b • ~ ~ ~ ¢ ~q;t ilillB .6t ~ 1liU be similarly_ genetically determined. If this is so, then the impactt•d
W~ ~ t> ? ~• 1: t.> ~ ~ '""C • ~ ~ ~ E ~ iJt iii • canine should occur with equal frequency on ~ither siJe in the
patient with a missing lateral incisor on one side and a peg-shaped
~ 1: ~ ;::_ Q ~ t iJf ~a- h '""( ~l Q. ;::_ h ~i. • or reduced lateral incisor on the other.
Remits ~ The canine aherration occurreJ far more fre4uently on
~~~~~~cM4~-~~~~~¢~-~
the sidt• of the diminutin lateral incisor.
J:: o :t ~ e: m.~YJ a .n -c ~l o. ~ ~ t ~ -c ~ ll: Condusion ~ There is an envaronmental factor in\"oln·d in the
palatal displacement of maxillary canines.
~~~~~~tM4~M~e~~~o§~"t"

~~~~w~~~~~tzo~&~~~~~~.o

~~ l:t ilill ~ ~ ~ 1ll~ W * iJt ~ tJ • ~ ~ ~ D il1llU E

Clinical Orthodontics and Research 2. 1999; 62-66
Copyright tD Munksgaard 1999, ISSN J39j-592i

~ e 118 bfJ ¢ -? ~ • B:ll:? ~~ '""C IPI :s: ~ t.:. ":*

~ ~ E ~ l:t. ~~ ~ o ~q;t illlB .6t ~ 1liU W~ c Acknowledgements: The authors wish to thank Professor
~~~~m~¢~YJG~~m~~il8bfJG.tt~. Gideon Bach, Head of the Department of Human Genetics at
the Hadassah University Hospital in Jerusalem for his valuable
~n~. :**~D-~E~~M~c~¢#ll: advice on the genetic aspects of this work.
~~~m~~~~#~~o~t~~~~¢~

J~eilet~o t~~ Ght.:.

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66 I Clm Onh Rn 2, 19<19 6l h6