Are patients with impacted canines referred too late?

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Objective To establish the appropriateness of timing of referrals for patients referred for the management of ectopic maxillary canines, and to evaluate the success of previous recommendations to educate referrers.

Design Retrospective clinical re-audit.

Setting Royal Surrey County Hospital NHS Foundation Trust.

Subjects and methods Data were collected retrospectively for 220 consecutive patients between January 2013 – December 2014 and compared to the gold standard based on the clinical guidelines for management of the palatally ectopic maxillary canine published by the Royal College of Surgeons of England in 2010 which states that all patients with an impacted canine should be referred by 12 years of age.

Results Ectopic maxillary canines represent a significant number of referrals to district general hospitals. One hundred and sixty-seven patients (76%) were referred late (>12 years) at a mean age of 14.1 years, >2 years later than the recommendations made in the Royal College Guidelines. Seventy-six percent of patients were not referred by 12 years of age compared to an audit in 2002 which found 45% delayed referral.

Conclusion Timing of referral was delayed compared with the Royal College Guidelines. An increase in delayed referral suggests that local education programmes introduced after the previous audit did not have a lasting effect.

Key Points

  • Reminds us that general dental practitioners are responsible for the detection and referral of patients with impacted canines.

  • Highlights that early diagnosis at 10 years of age facilitates interceptive extraction of primary canines, which can allow normalisation of eruption.

  • Highlights that early diagnosis can avoid the risk of damage to adjacent teeth.

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  1. 1

    Bass T P . Observation on the misplaced upper canine tooth. Dent Pract Dent Rec 1967; 18: 25–33.

  2. 2

    Cooke J, Wang H L . Canine impactions: Incidence and management. Int J Periodontics Restorative Dent 2006; 26: 483–491.

  3. 3

    McSherry P F . The ectopic maxillary canine: A review. Br J Orthod 1998; 23: 209–216.

  4. 4

    Ericson S, Kurol J . Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol 1986; 14: 172–176.

  5. 5

    Ericson S, Kurol J . Radiographic examination of ectopically erupting maxillary canines. Am J Ortho Dentofacial Orthop 1987; 91: 483–492.

  6. 6

    Bishara S E . Impacted maxillary canines: A review. Am J Orthod Dentofacial Orthop 1992; 101: 159–171.

  7. 7

    Peck S, Peck L, Kataja M . The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod 1994; 64: 249–256.

  8. 8

    Peck S, Peck L, Kataja M . Concomitant occurrence of canine malposition and tooth agenesis: evidence of orofacial genetic fields. Am J Orthod Dentofacial Orthop 2002; 122: 657–660.

  9. 9

    Zilberman Y, Cohen, Becker A. Familial trends in palatal canines, anomalous lateral incisors, and related phenomena. Euro J Orthod 1990; 12: 135–139.

  10. 10

    Brin I, Becker A, Shalhav M . Position of the maxillary permanent canine in relation to anomalous or missing lateral incisors: a population study. Euro J Orthod 1986; 8: 12–16.

  11. 11

    Hurme V O . Ranges of normalcy in the eruption of permanent teeth. J Dent Child 1949; 16: 11–15.

  12. 12

    British Orthodontic Society. Managing the developing dentition. A guide for dental practitioners. 2010. Available online at (accessed October 2016).

  13. 13

    Husain J, Burden D, McSherry P . Management of the palatally ectopic maxillary canine (Update of 1997 Guideline written by Burden D, Harper C, Mitchell L et al.). The Royal College of Surgeons of England, Faculty of Dental Surgery Clinical Guidelines, 2010. Available online at (accessed October 2016)

  14. 14

    Bruks A, Lennartsson B . The palatally displaced maxillary canine. A retrospective comparison between an interceptive and a corrective treatment group. Swed Dent J 1999; 23: 149–161.

  15. 15

    Ericson S, Kurol J . Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Euro J Orthod 1988; 10: 283–295.

  16. 16

    Power S M, Short M B . An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to favourable eruption. Br J Orthod 1993; 20: 215–223.

  17. 17

    Stewart J A, Heo G, Glover K E . Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop 2001; 119: 216–425.

  18. 18

    Becker A, Chaushu S . Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop 2003; 124: 509–514.

  19. 19

    Fleming P S, Scott P, Heidari N, DiBiase A T . Influence of radiographic position of ectopic canines on the duration of orthodontic treatment. Angle Orthod 2009; 79: 442–446.

  20. 20

    Mathews D P, Kokich V G . Palatally impacted canines: The case for preorthodontic uncovering and autonomous eruption. Am J Orthod Dentofacial Orthop 2013; 43: 450–458.

  21. 21

    Ericson S, Kurol J . Resorption of incisors after ectopic eruption of maxillary canines: A CT study. Angle Orthod 2000; 70: 415–423.

  22. 22

    Walker L, Enciso R, Mah J . Three-dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2005; 128: 418–423.

  23. 23

    Mourshed F . A roentogenographic study of dentigerous cysts. I. Incidence in a population sample. Oral Surg Oral Med Oral Pathol 1964; 18: 47–53.

  24. 24

    Hepworth C, Taylor N G, Jones A G et al. A regional audit of patients referred with impacted maxillary canines. South West Thames Clinical Effectiveness Group, 2002.

  25. 25

    O'Brien K, Wright J, Conboy F et al. Orthodontics: The effect of orthodontic referral guidelines: a randomised controlled trial. Br Dent J 2000; 188: 392–397.

  26. 26

    Hassan T, Nute S J . An audit of referral practice for patients with impacted palatal canines and the impact of referral guidelines. Br Dent J 2006; 200: 493–496.

  27. 27

    General Dental Council. Standards for the Dental Team. 2013. Available online at (accessed October 2016).

  28. 28

    NHS England. Consultant-led referral to treatment waiting times. March 2008 to September 2015. Available online at (accessed October 2016).

  29. 29

    Parkin N, Furness S, Shah A, Thind B, Marshman Z, Glenroy G, Dyer F, Benson P E . Extraction of primary (baby) teeth for unerupted palatally displaced permanent canine teeth in children. Cochrane Database Syst Rev. 2012; 12.

  30. 30

    Naoumova J, Kurol J, Kjellberg H . Extraction of the deciduous canine as an interceptive treatment in children with palatal displaced canines–part I: shall we extract the deciduous canine or not? Euro J Orthod 2014; cju040.

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The authors would like to acknowledge the support of the Royal Surrey County Hospital NHS Foundation Trust Research & Development scheme.

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Correspondence to D. Patel.

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Patel, D., Taylor, N. Are patients with impacted canines referred too late?. Br Dent J 221, 561–564 (2016) doi:10.1038/sj.bdj.2016.816

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