“The palatally impacted canine is a difficult orthodontic problem, often requiring surgical and orthodontic

cooperation” Schmidt & Kokich

The maxillary canine is one of the most frequently impacted teeth, with an

incidence of about 2 per cent of the population

Thilander and Jakobsson, 1968; Ericson and Kurol, 1986.

Palatal impaction is more common than labial

Thilander and Jakobsson, 1968 Jacoby, 1983

Stellzig et al., 1994 Ericson and Kurol, 2000

Ericson and Kurol suggested that diagnosis of canine impaction by no later than 10 years of age and early

corrective measures are of fundamental importance in reducing the risk of complications and more

invasive treatment

Ericson and Kurol, 1987

In the age group 10–13 years, the treatment of choice comprises

extraction of the primary canine and expansion of the dental arch. The

reported success rate of such interceptive procedures is 62–87.5

per cent Ericson and Kurol, 1988 Power and Short, 1993 Leonardi et al., 2004

Baccetti et al. 2008, 2009

Ericson S, Kurol J 1986 Radiographic assessment of maxillary canine eruption in

children with clinical signs of eruption disturbance. European Journal of

Orthodontics 8: 133–140

With later diagnosis, however, simple interceptive procedures are not as

effective. In such cases, combined surgical-

orthodontic treatment is commonly used to resolve palatal impaction though it is

often related to damage to adjacent teeth and supporting structures

Becker et al.,1983 Blair et al.,1998

Becker and Chaushu, 2003 Frank and Long, 2002

Zasciurinskiene et al., 2008

Heather Woloshyn, Jon Årtun, David B. Kennedy, and Donald R. Joondeph

Pulpal and periodontal reactions to orthodontic alignment of palatally impacted canines.

The Angle Orthodontist 1994;64(4):257-264

The purpose of this study was to evaluate differences in • periodontal and pulpal status • root length • and tooth alignment between contralateral maxillary lateral incisors, canines, and premolars in patients treated for unilateral impaction of maxillary canines.

Clinical examinations were performed on 32 patients,

Average age 22 years 11 months

Average post treatment observation period 3 years 7 months.

Probing attachment level was lower at the mesial (0.32) and distal (0.20) aspect of the previously impacted canine and at the distal aspect of the adjacent lateral incisor (0.29)

Crestal bone height was lower at the mesial aspect (0.52) of

the previously impacted canine and at the distal aspect (0.86) of the adjacent lateral incisor.

The roots of the lateral incisors (1.33) and premolars (1.27) adjacent to the previously

impacted canines were shorter.

Pulpal obliteration was observed in six previously impacted canines (21%), and pulp necrosis in one

previously impacted canine.

The relationship between the magnitude of vascular impairment and

extreme types of tooth movement ?

Approximately 40% of the previously impacted canines exhibited noticeable

relapse and were judged to be • intruded, • lingually displaced, • mesially rotated, • as well as discolored.

The previously impacted canine could be identified on post treatment color slides in approximately 75% of the

cases.

Advocates of the closed eruption approach note such benefits as • a possibility to influence the direction

of the extrusion of the impacted tooth, • patient comfort during the healing

process (Chaushu et al., 2005; Gharaibeh and Al-Nimri, 2008),

• reduced surgical bleeding,

The clinicians who support open exposure technique and spontaneous eruption of the canine claim several potential advantages: • the ability to observe the impacted tooth

movement during treatment, • no need of attachment bonding, • time saving during surgical procedure (Pearson

et al., 1997; Gharaibeh and Al-Nimri, 2008), • fewer repeated operations necessary (Fournier

et al., 1982; Pearson et al., 1997),

n=28 canines post-ortho 2y11m

average age 23y7mo

Schmidt & Kokich• Probing attachment loss - distolingual of the

lateral incisor (0.45mm) and distobuccal of the premolar (0.28mm)

• Crestal bone loss mesial & distal of the lateral incisor (0.76 and 0.29mm)

• Root shortening of the cuspid and lateral incisor (1.08 and 1.87mm)

• Identify the former impaction: 79%

Palatally impacted maxillary canines: choice of surgical-orthodontic treatment method does not influence post-treatment periodontal status. A controlled prospective

study.

Smailiene D1, Kavaliauskiene A, Pacauskiene I, Zasciurinskiene E, Bjerklin K

Eur J Orthod. 2013 Dec;35(6):803-10.

n=43 open = 22

closed = 21 quasi-randomized = alternate

randomization Kokich & Mathews (1993) techniques

In group 2, extrusion of the impacted tooth was initiated 1 week after surgery by means of a ballista loop on the additional stainless steel

0.016 inch archwire (Kornhauser et al., 1996).

An additional Sentalloy 0.014 inch archwire

Every second patient was assigned to the open technique group.

All patients were treated by one of the authors (DS)

All surgical procedures were undertaken by the same oral surgeon.

Periodontal & radiographic exam findings:

Bone loss distal of the lateral incisor and mesial of the cuspid

“It is concluded that choice of surgical method is not associated with any significant differences in post-treatment periodontal status of palatally impacted

canines and adjacent teeth.”

• “There are no differences in outcomes when performing either an open or a closed surgical exposure for an unerupted palatally displaced canine in the maxilla…however the quality of the evidence is low”

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Professionals & Members | British Orthodontic Society Foundation (BOSF) | BOSF Grants and Awards | Grant Recipients | Dr NicolaParkin BOSF Grant 2004

Dr Nicola Parkin BOSF Grant 2004Surgical exposure of palatally displaced canines (PDC). A randomised clinical trial.

Primary investigator

Dr Nicola Parkin (Sheffield)

Secondary investigators

Philip Benson (Sheffield), Ann Marie Smith (Derby), David Tinsley (Chesterfield), Richard Milner (Sheffield)

Principle Research Question

Is there any difference in the periodontal health of orthodontically aligned ectopic canines that have been exposed with an open (left)versus a closed technique (right)?

Other outcomes

Economic: Is one technique more expensive?Patient response: Which technique causes the least discomfort to the patient?

Progress

We began this research project in the summer of 2003. Owing to a number of ‘teething’ problems, for example surgical colleaguesconfusing open with closed techniques, our original sample size target has had to increase substantially! By December 2006 we recruited81 patients, this allowed compensation for incorrect surgery, failure to diagnose PDC and drop outs. Forty-one participants were allocatedto open exposure and forty to closed exposure. Some patients are taking much longer than others to treat (one patient took 50 months!)and we still have 7 patients in active treatment.

Analysis

We are assessing periodontal outcome clinically, with photographs, study models and radiographs.

My periodontal colleagues assure me that all the patients are especially impressed with the Williams pressure sensitive periodontalprobes that we are using. (It is a problem getting patients back in to carry out these measurements, the Williams pressure sensitive probecould be one reason, especially for those participants with gingival inflammation!)

We are taking study model records at 3 months post debond and 1 year post debond. Records appointments generally takeapproximately 90 minutes (30 minutes in the dental chair and 60 minutes in ‘our very busy’ xray department). Financial remuneration hashelped ensure attendance at these appointments.

I am just beginning to measure the study models. I am looking at gingival recession, width of attached gingivae and position of canines.One of the things I am finding out is that retention of PDC is extremely important, particularly for the 1 year post debond visit.

Publications

PARKIN N, DEERY C, SMITH AM, TINSLEY D, SANDLER J, BENSON PE. No difference in surgical outcomes between open and closedexposure of palatally displaced maxillary canines. J Oral Maxillofac Surg. 2012 Sep; 70(9): 2026-34

PARKIN N & BENSON P. Current ideas on the management of palatally displaced canines: Faculty Dental Journal January 2011, Volume2, Issue 1

PARKIN, N. (2009) Clarifying points. Br Dent J, 207, 567-8.

PARKIN, N., BENSON, P. E., SHAH, A., THIND, B., MARSHMAN, Z., GLENROY, G. & DYER, F. (2009a) Extraction of primary (baby)teeth for unerupted palatally displaced permanent canine teeth in children. Cochrane Database Syst Rev, CD004621.

PARKIN, N., BENSON, P. E., THIND, B. & SHAH, A. (2008) Open versus closed surgical exposure of canine teeth that are displaced inthe roof of the mouth. Cochrane Database Syst Rev, CD006966.

PARKIN et al: Periodontal health between palatally displaced canines treated with either an Open or Closed surgical technique in youngpeope undergoing fixed orthodontic treatment: A multi-centre randomized controlled trial. In press: American Journal of Orthodontics &Dentofacial Orthopedics

PARKIN N, FURNESS S, SHAH A, THIND B, MARSHMAN Z, GLENROY G, DYER F, BENSON PE. Extraction of primary (baby) teeth forunerupted palatally displaced permanent canine teeth in children. Update, Cochrane Database Syst Rev. 2012 Dec

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“However, since we have experienced failure of teeth to erupt despite the application of traction in patients in their fourth and fifth decades of life, we

have advised placement of a temporary anchorage device in the palate at the time of closed exposure and the immediate application of elastic traction for

several months, until positive signs of movement are seen. Only then do we place orthodontic

appliances on the other teeth and reevaluate our treatment options in light of the outcome”