What should be done about the upper right canine tooth, Atlas number three?

Management of Upper Right Canine (Tooth #3)

The upper right canine should be assessed for impaction, displacement, or other pathology using orthopantomography as the initial diagnostic examination, with treatment decisions based on the specific clinical findings and the tooth's position, angulation, and relationship to adjacent structures. 1

Initial Clinical Assessment

The upper right canine (tooth #3 in the Universal Numbering System) requires systematic evaluation to determine appropriate management:

• Identify whether the tooth is primary or permanent, as this fundamentally changes management approach—children under 5 years typically have primary dentition, while after age 8-9 years, canines may be permanent 2
• Assess for trauma-related issues including tooth mobility, displacement, occlusal disturbances, sensitivity to temperature, and sulcular bleeding, as these indicate specific injury patterns requiring different interventions 2
• Evaluate for impaction or eruption anomalies, particularly if the patient is over 6 years old and the permanent canine has not erupted normally, as canine impaction occurs in approximately 1.7-2% of the population 3, 1

Diagnostic Imaging Approach

For suspected canine impaction or positional abnormalities, orthopantomography (panoramic radiograph) is the mandatory first-line imaging study and should not be performed before age 6 when permanent tooth buds become visible 2, 1:

• OPT provides adequate information on canine position, vertical height, angulation to midline, overlap with adjacent incisors, and root apex position—the four critical prognostic categories 1, 3
• Periapical radiography may supplement OPT for upper incisor-canine region assessment with approximately 80% diagnostic accuracy, though it has limited anatomical field of view 2, 1
• Reserve CBCT for specific indications only, following the ALARA principle with targeted, limited field-of-view scans when 2D imaging cannot provide adequate information 2, 1

When CBCT Is Essential

CBCT becomes necessary in specific high-risk scenarios where 2D imaging is insufficient 1:

• When OPT suggests contact between the impacted canine and critical structures (sensitivity 90%, specificity 85%) 1
• For assessing root resorption of lateral incisors by impacted canines, as OPT dramatically underestimates both detection and severity with a 70% false negative rate 1
• When tooth transposition is associated with dental impaction 2
• When complex root canal anatomy is suspected, as C-shaped configurations cannot be accurately predicted on 2D imaging 4

Treatment Decision Algorithm

For Palatally Displaced Canines

Both open and closed surgical exposure techniques are equally successful (RR 0.99,95% CI 0.93-1.06) with no significant differences in dental aesthetics, pain, periodontal health, or treatment time 5:

• Closed technique: Uncover the canine, attach eyelet and gold chain, suture palatal mucosa back over the tooth, then move it into position covered by mucosa 5
• Open technique: Uncover the canine and remove overlying palatal tissue to leave it exposed for direct visualization during alignment 5
• Complications are rare but include post-operative infection, gold chain detachment, and pain during alignment when the chain penetrates through gum tissue 5

For Tooth Transposition

If complete transposition of the canine and first premolar is confirmed (involving both crowns and roots), orthodontic correction of the transposition is possible with proper treatment planning 6:

• Treatment typically requires 24-25 months of active orthodontic intervention 6
• OPT may be sufficient for treatment planning in straightforward cases 2
• CBCT is useful when transposition is associated with impaction 2

For Trauma-Related Injuries

Management differs significantly between primary and permanent dentition 2:

• Concussion (tender to touch, no mobility/displacement, no sulcular bleeding): Conservative management with monitoring 2
• Subluxation (abnormal mobility, no displacement, sulcular bleeding present): Requires dental referral 2
• Luxation injuries (lateral, extrusive, or intrusive displacement): Immediate dental referral required 2

Critical Pitfalls to Avoid

• Never rely solely on OPT for root resorption assessment, as it underestimates both presence and severity in 70% of cases 1
• Do not perform radiological examination before age 6 unless trauma or acute pathology is present 2, 1
• Avoid using CBCT as initial diagnostic examination unless specific indications exist, to minimize radiation exposure 2, 1
• Do not assume canine position based on clinical examination alone—radiographic confirmation is essential for treatment planning 1, 3
• Assess for neurologic injury and cervical spine protection if trauma occurred, as proximity to cranium necessitates evaluation for concussion or intracranial injury 2