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Unusual intraosseous transmigration of impacted tooth - report of three cases

International Journal of Oral & Maxillofacial Pathology. 2012;3(3):56-60 ISSN 2231 – 2250
Available online at or Case Report
Intraosseous Transmigration of Impacted Canines: Report of Five Cases
Sulabha AN, Sachin Deshpande, Sameer C
Transmigration is rare and unusual anomaly involving the intraosseous migration of impacted
tooth across midline regardless of the distance. This occurs almost exclusively with mandibular
canines. Etiology is still unclear and is not well documented in the literature. Transmigration can
occur as isolated finding or in association with other findings such as dentigerous cyst,
odontomas, impactions of other teeth etc. Transmigrated canines are particularly significant due
to aesthetic and functional importance. Early radiographic examination of the patient is important
for the treatment. More documentation of this anomaly and future studies may lead to a better
understanding of this rare anomaly, its etiology and improvement of the classification criteria. This
paper presents five cases of transmigration of mandibular canines of which two were associated
with dentigerous cyst, one associated with bodily rotation of canine, one associated with absence
of third molars on right side.

: Impacted Canine;Tooth Migration;Transmigration;Intraosseous;Dentigerous Cyst;

Sulabha AN, Sachin Deshpande, Sameer C. Intraosseous Transmigration of Impacted Canines: Report of
Five Cases. International Journal of Oral and Maxillofacial Pathology; 2012:3(3):56-60. International
Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private
Limited. All Rights Reserved.

Received on: 16/06/2012 Accepted on: 09/09/2012

Since impacted or transmigrated teeth are Impacted teeth are important in dentistry and important especially in terms of orthodontic are particularly significant in orthodontics, treatment planning, these teeth must be especially if the impacted tooth is a canine. diagnosed clinically and radiographically. The occurrence of impacted mandibular Early diagnosis with timely treatment can canine is rarer than maxillary canine and it is help dentist preserve the canines, which even rarer phenomenon when such an play an important role in both aesthetics and impacted mandibular canine migrates to the function in human dentition.2 Future studies other side of mandible crossing the midline.1 and more documentation of this anomaly This rare phenomenon of the tooth crossing may lead to it's inclusion as one of developmental anomalies of teeth and better understanding of this rare condition.5 exclusively with mandibular canines2 with an incidence of 0.1%.3 The present paper reports five cases of transmigrated canines of which two were The exact mechanism of transmigration is associated with dentigerous cyst, one with not clear.2 This anomaly is most often absence of two third molars, other was associated with bodily rotated lower canine pathology, and usually cannot be detected in mesiodistal direction. during the routine clinical examination. Case Report:
discovered on routine intraoral periapical view because the tooth is most frequently The 22 year old male reported to department horizontally impacted under the apices of of oral medicine with a complaint of retained permanent teeth adjacent to the mandibular mandibular right and left primary canine. border. Similarly a palatally impacted canine Intraoral examination showed absence of is sometimes horizontal positioned very high both permanent lower canines and retained in the palatal vault, close to the floor of nasal both lower primary canines. Panoramic view cavity and thus might not be detected. Therefore when any permanent tooth is canines to be impacted. The right and left mandibular canines were unerupted and both were mesioangularly impacted with the left canine crossing the midline and the right 2012 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved

ISSN 2231 – 2250
Intraosseous Transmigration of Impacted Canines. 57
canine positioned very close to the midline. completely edentulous. The panoramic Right upper and lower third molars were radiograph indicated the left mandibular absent. There was no pathologic finding canine was impacted mesioangularly with associated with both impacted canines. The part of crown crossing the midline. The patient was asymptomatic and was informed crown of this canine was surrounded by a of the condition and radiographic monitoring cystic radiolucency (Fig 3). Patient was was strongly recommended (Fig 1). treated by surgical removal of cyst along with the involved tooth and histopathological examination confirmed the cyst to be dentigerous cyst. showing the both the mandibular left canine crossing the midline and right canine close showing the left mesioangularly impacted canine surrounded by a cystic cavity. A 24 years old male reported to the department of Oral Medicine for oral A 17 years male reported to department of prophylaxis. Intraoral examination revealed oral medicine with a complaint of swelling in absence of right permanent mandibular the lower front of jaw. Intraoral examination canine and retention of right mandibular revealed a nontender, slightly firm swelling primary canine. Radiographic examination in the left side of lower jaw with the impacted right canine at the inferior border of the mandible with its crown positioned below the root apices of right premolars. mandibular canine across the midline and Bodily rotation of left canine in mesiodistal was associated with radiolucency along with direction was seen along with impaction of buccal cortical plate expansion suggestive of all the third molars (Fig 2). Patient was dentigerous cyst (Fig 4). Surgically the cyst informed of the condition and regular was enucleated along with the removal of radiographic follow up was advised. histopathological examination confirmed the lesion to be dentigerous cyst. showing horizontally impacted canine of right side near inferior border of mandible below the apices of premolar. showing impacted canine crossing the mid line and associated with large cystic space. A 69 years male reported to department of oral medicine for construction of prosthesis. A 12 years old male child reported to Intraoral examination revealed slight bulge in department of oral medicine with a complaint the lower anterior region. Patient was of decayed tooth in right lower back region. 58 Sulabha AN et al.,
ISSN 2231 - 2250
possible to decide whether pathological mesioangular impaction of left canine below the apices of the left incisors with it's transmigration of the teeth or not.5 Aydin and follicular space just touching the midline. According to Howard's criteria complete transmigration associated with dentigerous transmigration was expected. Patient was cyst. Transmigration is also associated with informed of the condition and radiographic other pathological conditions such as follow up was advised. odontomas, hypodontia, impaction of other teeth3,6. The other suggested etiologies are Discussion
premature loss of deciduous teeth, retention of deciduous teeth, inadequate space, phenomenon.3 The term transmigration was first used by Ando et al in 1964. Tarsitano et unfavorable alveolar length, genetics, root phenomenon of an unerupted mandibular stump obstacle would be sufficient to divert canine the midline. Joshi and Acluck et al a tooth from its original path of eruption.6,9,10 suggested that the tendency of a canine to Howard expected the older patient would cross the midline suture is a more important show greater distance of travel because a consideration than actual distance of longer time had been available for migratory migration after crossing the midline.2 canine to travel.1 Although the first published cases were Mupparapu11 described the five patterns for detected as a result of neurological changes transmigrated mandibular canine. caused by the compression of lower dental Type 1: Canine positioned mesioangularly
nerve by the impacted tooth radiology has across the midline within jaw bone, labial or made it possible to detect similar but lingual to anterior teeth and crown portion of symptom less cases allowing an adequate the tooth crossing the midline. assessment of the percentages of cases Type 2: Canine horizontally impacted near
which are presented clinically.3 the inferior border of mandible below the apices of the incisors. Patient presenting this anomaly range from Type 3: Canine erupting either mesial or
8-62 years.3 One of case in the present distal to the opposing canine. paper was 69 years old and was completely Type 4: Canine horizontally impacted near
edentulous. Therefore transmigration can be the inferior border of the mandible below the seen in any age group. Transmigrations are apices of either premolar or molar on the more in females, with female to male ratio being 2:1,3 But all our cases were of male Type 5: Canine positioned vertically in the
midline (the long axis of the tooth crossing the midline) irrespective of eruption status. The etiology and exact mechanism are still not clear. Number of factors has been Type 1 is most common, followed by type 2, suggested. Abnormal displacement of the type 4, type 3 and type 5. The present case dental lamina in the embryonic life is reports of 1, 3, 4 and 5 were of type 1 and commonly accepted explanation of the case 2 was of type 4 pattern. cause of displacement and non eruption of such cases. Some suggested it may be due Howard observed that those unerupted to abnormally strong eruptive force and canines that lie between 250 and 300 in the conical shape of the canine which drives mid saggital plane do not migrate across the canine through dense symphysis.6 Some midline. Those canines that lie between 300 suggested that agenesis of the adjacent and 950 tend to cross the midline. An teeth in particular the lateral incisor, may overlap appears to exist between 300 and favor the retention of primary canines and 500, when angle exceeds 50 crossing the excess space in dental arch may midline becomes a rule.6 In case 1, bilateral account for the absence of a correct guide transmigration might be possible, as right for eruption.7 Al-Waheidi8 and others5 suggested that transmigrated canines are transmigration and has migrated close to associated with cystic lesions and that the presence of cyst at the crown of the canine From the present case reports it can be However it was also noted that it may not be ISSN 2231 – 2250
Intraosseous Transmigration of Impacted Canines. 59
1) All the cases except case 3 had retained explain the nature of this anomaly. Future primary canines. studies and reports of more cases showing 2) The tooth deviates for no apparent transmigration of canine help to better understand their mechanism of eruption and 3) The direction of all the transmigrant improvement of classification criteria. canines was mesial. 4) In case 3, transmigration occurred in Author Affiliation
1. Dr.Sulabha AN, Professor, Department of Oral transmigrant had just crossed the midline though longer time was available for migrant to travel a greater distance. Department of Oral and Maxillofacial Surgery, Al- 5) Four cases were associated with some Ameen Dental College and Hospital, Bijapur - findings case 1 was associated with 586108, Karnataka, India. absence of right side third molars, case 2 was associated with bodily rotation of other lower canine , case 3 and 4 were associated We would like to thank all the staff members from dentigerous cyst. Department of Pedodontics and Oral Medicine for 6) All cases of transmigration were seen in their support & cooperation. References
The several treatment options proposed for 1. Sumer P, Sumer M, Ozden B, Otan F. Transmigration of mandibular canines: A appears to the most favored, rather than report of six cases and a review of the heroic effort to bring the tooth back to its position. It is also indicated in existence of 2007;8(3):104-10. pressure resorption of roots of adjacent 2. 2.Kumar S, Urala AS, Kamath AT, teeth, periodontal problems, infections, Jayaswal P, Valiathan A. Unusual intraosseous transmigration of impacted symptoms etc. Contra lateral nerve should tooth. Imaging Sci Dent 2012;42:47-54. 3. Torres Lagares D, Flores Ruiz R, transmigrated tooth as they maintain their Infante-Cossio P, Garcia-Calderon M, nerve supply from original side. If the Gutierrez-Perez JL. Transmigration of mandibular incisors are in normal position impacted lower canines: case report and and space for the transmigrated canine is review of literature. Med Oral Pathol Oral Cir Buccal 2006;11:E171-4. Orthodontic treatment can be done to bring palatally impacted canine. Am J Orthod back the labially impacted transmigrated Dentofacial Orthop 2005;127:360-3. canine to position. However if the crown of 5. Aydin U, Yilmaz HH. Transmigration of such a tooth migrates past the opposite incisor area or if the apex is seen to have Radiol 2003;32:198-200. migrated past the apex of adjacent lateral 6. Camilleri S, Scerri E. Transmigration of incisor it is impossible to bring back it into mandibular canines – A review of the original place. Some authors believe that literature and report of five cases. Angle symptom less non erupted teeth can be left Orthod 2003;73(6):753-62. in place. In these patients, a series of 7. Vichi M, Franchi L. The transmigration of successive radiographs should be taken the permanent lower canine. Minerva periodically. In the present cases, case-1 Stomatol 1991;40:579-89. and case-2 and case-5 were kept under observation; case-3 and case-4 were treated unerupted mandibular canine with a surgically for cyst followed by extraction of literature review and a report of five cases. Quintessence Int 1996;27:27-31. 9. Peck S. On the phenomenon of To conclude, transmigration is a rare event intraosseous migration of nonerupting and early radiographic examination of teeth. Am J Orthod Dentofacial Orthop patient is important for treatment planning. Literature has shown transmigration in both 10. Joshi MR. Transmigrant mandibular mandible and maxilla with higher frequency canine: a record of 28 cases and in mandible with no specific etiology to 60 Sulabha AN et al.,
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retrospective review of the literature. 15. Acluck A, Nagpal A, Setty S, Pai K, Angle Orthod 2001;71(1):12-22. Sunny J. Transmigration of impacted 11. Mupparapu M. Patterns of intraosseous mandibular canines: report of four transmigration and ectopic mandibular cases. J Can Dent Assoc 2006;72:249- canine: review of literature and report of nine additional cases. Dentomaxillofac 16. Miranti R, Levbarg M. Extraction of a Radiol 2002;31(6):335-60. 12. Aras MM, Buyukkurt MC, Yolcu U, Ertas canines: report of case. J Am Dent U, Dayi E. Transmigrant maxillary Assoc 1974;88:607-10. canines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e48-52. Author Correspondence
13. Robellato J, Schabel B. Treatment of a patient with an impacted transmigrant Professor, Department of Oral Medicine and Radiology, Al-Ameen Dental College and Hospital, 2003;73(3):328-36. Bijapur- 586108, Karnataka .India. 14. Wertz RA. Treatment of transmigrated Ph: +91-9449518128 Email: Dentofacial Orthop .1994;106:419-27. Source of Support: Nil, Conflict of Interest: None Declared.



Femtosecond-assisted intrastromal corneal cross-linking forearly and moderate keratoconus M. Balidis,1,2 V.E. Konidaris,2 G. Ioannidis,1,3 A.J. Kanellopoulos4,5 months. Our study demonstrates the safety and efficacy ofthe proposed method. Purpose: To evaluate the effect of Femtosecond-assisted Key words: keratoconus, femtosecond, cross-linking.

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British Journal of Anaesthesia 1996; 76: 484–486 CLINICAL INVESTIGATIONS Dose requirements, efficacy and side effects of morphine and pethidine delivered by patient-controlled analgesia after gynaecological surgery G. STANLEY, B. APPADU, M. MEAD AND D. J. ROWBOTHAM patients gave written informed consent to the study which was approved by the local Ethics Committee.