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Journal of Oral Science, Vol. 60, No. 4, 552-556, 2018

Original

Periodontal status of buccally and palatally impacted

maxillary canines after surgical-orthodontic treatment
with open technique
Stefano Mummolo1), Alessandro Nota1,2), Maria Elena De Felice1),
Domenico Marcattili1), Simona Tecco2), and Giuseppe Marzo1)
1)Department of Life Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
2)Dental School, Vita-Salute San Raffaele University, Milan, Italy

(Received October 20, 2017; Accepted December 25, 2017)

Abstract: This study investigated differences in peri-
odontal health variables between buccally impacted
maxillary canines (BIMC) and palatally impacted
maxillary canines (PIMC) after surgical-orthodontic
treatment with open technique. Nineteen patients were
enrolled: 10 with unilateral BIMC (5 men, 5 women;
mean age 18.50 ± 1.96 years) and 9 with unilateral
PIMC (4 men, 5 women; mean age 19.44 ± 2.40 years).
Probing depth and keratinized tissue were recorded
12 months after surgical-orthodontic treatment, and
the differences between the 2 sides were analyzed as
primary outcomes. In addition, data for BIMC and
PIMC were directly compared. In the BIMC group,
probing depths were significantly higher for lateral
incisors than for the untreated side (P = 0.044), and
keratinized tissue values were significantly lower for
canines than for the untreated side (P = 0.006). No
significant differences were observed in the PIMC
group. In BIMC, surgical-orthodontic treatment
with open technique resulted in loss of periodontal
keratinized tissue in the treated tooth and periodontal
attachment loss in adjacent lateral incisors. However,
the periodontal status of PIMC was not affected by
surgical-orthodontic treatment with open technique.
Correspondence to Dr. Alessandro Nota, Dental School, Vita-
Salute San Raffaele University, Via Olgettina, 58 Milano 20132,
Italy
Fax: +39-0396774082 E-mail: dr.alessandro.nota@gmail.com
J-STAGE Advance Publication: July 9, 2018
doi.org/10.2334/josnusd.17-0394
DN/JST.JSTAGE/josnusd/17-0394
Keywords: impacted teeth; canine; periodontal
attachment; keratinized tissue; orthodontic
appliances; orthodontic movement.
Introduction
Maxillary canine impaction is a common clinical condi-
tion in dentistry (frequency 0.2-2.8%) (1). About 4%
of patients referred to orthodontists are affected by this
condition, and the ratio is 4:1 for palatally vs buccally
impacted canines (2-5).
Transverse maxillary deficiency is associated with
maxillary canine impaction (6-8); thus, early interceptive
orthodontic treatment with rapid maxillary expansion
is effective in increasing the eruption rate of displaced
maxillary canines (9-11). In the absence of such treatment,
maxillary canine impaction requires comprehensive
orthodontic-surgical treatment, including surgical expo-
sure of the canine crown and orthodontic traction to bring
the impacted canine into occlusion (12-14).
Existing evidence (15-17) is unclear regarding peri-
odontal outcomes after surgical exposure and subsequent
orthodontic alignment of displaced canines—some
studies reported periodontal problems, included loss of
alveolar bone height, increased pocket probing depths,
and loss of attached gingivae or found only a limited
periodontal effect (17). The effects of open and closed
technique on ultimate periodontal status has been
extensively investigated (5,18). Although studies are less
critical of periodontal outcomes for closed technique, a
systematic review noted that the results were similar to
those for open technique and found no evidence favoring

open or closed technique (19,20).
At the authors’ knowledge, no previous study has
compared post-treatment periodontal status between
buccally impacted maxillary canines (BIMC) and
palatally impacted maxillary canines (PIMC). This
prospective observational study investigated differ-
ences in periodontal health parameters between BIMC
and PIMC after surgical-orthodontic treatment with
open technique and compared the findings with those
from contralateral physiologically erupted canines. The
primary study outcomes were differences in probing
depth (PD) and keratinized tissue (KT) between BIMC
and PIMC and their respective contralateral normally
erupted canine. The secondary outcomes were the differ-
ences in PD and KT values between BIMC and PIMC.
Materials and Methods
Subjects
In this prospective observational clinical study, 10 patients
with unilateral BIMC (5 men, 5 women; mean age 18.50
± 1.96 years) and 9 patients with unilateral PIMC (4 men,
5 women; mean age 19.44 ± 2.40 years) were enrolled
after a thorough clinical examination and radiographic
assessment. All patients were enrolled after providing
written informed consent. The study was conducted in
accordance with the Declaration of Helsinki and was
approved by the ethics committee of the University of
L’Aquila (Document No. DR206/2013).
Unilateral impaction was first evaluated by clinical
examination when a permanent maxillary canine was
absent in the dental arch after the expected eruption
time and a physiologically erupted contralateral canine
was present. The deciduous canine might still be present
on the impaction side of the maxillary dental arch. A
diagnosis of impaction was confirmed by conventional
panoramic X-rays and lateral cephalograms. In some
cases, cone-beam computed tomography was used to
determine the location (buccal or palatal) of the impacted
canine.
Additional inclusion criteria were presence of a
normally erupted and correctly positioned contralateral
canine, complete permanent dentition, submucosal
impaction of the impacted canine, absence of periodontal
disease, good level of oral hygiene, and absence of peri-
odontal inflammation, which was defined as plaque index
(PI) and bleeding on probing values of 0 and the absence
of clinical signs of gingival inflammation, gingival reces-
sion, and tooth mobility.
Surgical-orthodontic procedure
The patients underwent standardized combined surgical-
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orthodontic treatment with open technique after initial
orthodontic treatment to achieve sufficient space for the
impacted canine. In the BIMC and PIMC groups, an
apically repositioned full-thickness mucoperiosteal flap
and operculectomy were respectively used to expose the
impacted canine.
To begin traction, a button was placed at the crown
level in the exposed and most accessible surface of the
tooth and tied with elastic thread. To avoid damage to the
periodontal tissue and the canine, the elastic thread was
replaced approximately every 15 days to ensure slow,
constant traction. The follicular envelope, if present, was
removed down to the cementoenamel junction because
of the possibility it might prevent bone healing and reat-
tachment of the periodontal ligament to the tooth. In both
cases, the canine was moved into alignment above the
mucosa by applying orthodontic traction with an elastic
thread. All surgical and orthodontic treatments were
conducted by the same expert operator (S.M.).
Periodontal evaluation
Periodontal measurements were recorded by using a
World Health Organization periodontal probe, 12 months
after the end of orthodontic treatment and removal of
the orthodontic appliance. Two periodontal variables
were recorded and analyzed in treated and normally
erupted canines. PD was recorded as the mean at 6 sites
(mesiobuccal, midbuccal, distobuccal, mesiopalatal,
midpalatal, and distopalatal) on each of the treated and
control canines. PD was also recorded at sites adjacent
to upper lateral incisors (distal site) and first bicuspids
(mesial site). KT was measured from the gingival margin
to the mucogingival junction, at the medial position of
the buccal aspect of the crown. KT was also recorded for
upper lateral incisors and first bicuspids. All periodontal
measurements were made by the same expert operator
(D.M.), who was blinded to the study goals and to the
presence of an orthodontically erupted canine.
Statistical analysis
The primary outcomes of this study were the differ-
ences in PD and KT between BIMC and PIMC and
their respective contralateral normally erupted canine.
Because of the small sample size, the Mann-Whitney U
test was used to compare differences between the 2 sides.
The secondary outcomes were the differences in PD
and KT values between BIMC and PIMC, which were
also analyzed with the Mann-Whitney U test. Statistical
significance was defined as a P value of less than 0.05.
Post hoc power analysis was performed for the primary
outcome.
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Table 1 Results of analysis of pocket depth

Treated Control Mann-Whitney U
Mean (mm) SD Mean (mm) SD Difference Significance
Canine 2.75 0.54 2.40 0.52 0.35 n.s.
BIMC Lateral incisor* 3.15 0.94 2.40 0.66 0.75 0.044
First premolar 2.40 0.66 2.30 0.48 0.10 n.s.
Canine 2.33 0.50 2.11 0.33 0.22 n.s.
PIMC Lateral incisor* 2.22 0.44 2.39 0.60 −0.17 n.s.
First premolar 2.00 0.00 2.11 0.22 −0.11 n.s.
*: Statistical significance after comparison of BIMC and PIMC; BIMC: Buccally impacted maxillary canines; PIMC: Palatally impacted
maxillary canines; SD: Standard deviation; n.s.: not significant.

Table 2 Results of analysis of keratinized tissue

    Treated Control   Mann-Whitney U
    Mean (mm) SD Mean (mm) SD Difference Significance
Canine* 2.35 0.85 3.35 0.47 −1.00 0.006
BIMC Lateral incisor 3.50 0.47 3.75 0.49 −0.25 n.s.
First premolar 1.75 0.59 2.00 0.47 −0.25 n.s.
Canine* 3.22 0.75 3.56 0.39 −0.33 n.s.
PIMC Lateral incisor 3.61 0.55 3.83 0.61 −0.22 n.s.
First premolar 2.00 0.25 1.94 0.46 0.06 n.s.
*: Statistical significance after comparison of BIMC and PIMC; BIMC: Buccally impacted maxillary canines; PIMC: Palatally impacted
maxillary canines; SD: Standard deviation; n.s.: not significant.

Results Statistical power

A total of 19 patients with unilateral maxillary canine
impaction were successfully treated. PD and KT peri-
odontal values were recorded, analyzed with descriptive
statistics, and expressed as means and standard devia-
tions. The mean time for orthodontic eruption was 5.5 ±
1.4 months in the BIMC group and 5.7 ± 1.1 months in
the PIMC group.
PD (Table 1)
In general, mean PD was higher in both treatment groups
than in their respective control groups. The difference
was statistically significant only for the lateral incisor in
the BIMC group (BIMC 3.15 mm, BIMCc 2.40 mm; P =
0.044). Furthermore, the difference in mean PD between
BIMC and PIMC was statistically significant for lateral
incisors (P = 0.012).
KT (Table 2)
Mean KT was generally lower in both treatment groups
than in their respective control groups. This difference
was statistically significant only for the canine in the
BIMC group (BIMC 2.35 mm, BIMCc 3.35 mm; P =
0.006). In addition, the difference in mean KT between
BIMC and PIMC was statistically significant for canines
(P = 0.021).
The post hoc power calculation for the primary analysis
showed a sample power of 76-96%.
Discussion
Previous studies (15,17) have yielded conflicting findings
regarding periodontal outcomes after surgical exposure
and subsequent orthodontic alignment of submucosal
impacted canines; some reported periodontal problems
such as loss of alveolar bone height, increased pocket
PDs, and loss of attached gingivae or found that treat-
ment had a limited periodontal effect (17). In the present
study, the periodontal outcome after orthodontic erup-
tion was significantly worse in the BIMC group than in
physiologically erupted contralateral canines. The BIMC
group had a 1 mm lower mean KT, and the adjacent
lateral incisors had a 0.75 mm higher PD. This result
is not consistent with the results of a recent literature
review, which found no significant differences between
BIMC and untreated canines (5,21). However, that report
conceded that data are limited on periodontal outcomes
for BIMC after surgical-orthodontic treatment.
Analysis of periodontal variables in the PIMC group
showed no differences between treated canines and the
contralateral untreated control group. A previous study
(17) reported a significant difference of 0.2-0.6 mm in
periodontal attachment between operated and unoper-
ated PIMC, but the difference was considered clinically

irrelevant.
With respect to the present primary outcomes, direct
comparison of the 2 treatment groups showed that BIMC
had a significantly worse post-treatment KT, about
0.9 mm less than that of PIMC. Moreover, the BIMC
adjacent lateral incisor at the distal site had a 0.9 mm
significantly greater PD than that of the PIMC adjacent
lateral incisor. Thus, BIMC appear to be associated with
worse periodontal outcomes.
To our knowledge, only one previous study (22)
examined the effects of the type of canine impaction on
post-treatment PD and KT outcomes. That report found
no significant differences in PD, but a significantly
higher KT (by about 0.5 mm) in PIMC as compared with
BIMC. These results are consistent with our findings,
which suggest that a treated BIMC has about 1 mm less
KT than its contralateral tooth and that the PD of the
adjacent lateral incisor will increase by about 0.75 mm.
This study is limited by its small sample size; thus,
future studies with bigger samples should be encouraged.
Nevertheless, the post hoc power analysis of the primary
outcome of the study yielded excellent results. A second
limitation of this study is that only open technique was
evaluated.
The present results indicate that clinicians should be
aware that when BIMC are surgically exposed with open
technique and erupted with orthodontic traction, they
will likely lose about 1 mm of KT, as compared to physi-
ological eruption. Moreover, the adjacent lateral incisor
will develop an attachment loss of about 0.75 mm. This
information is useful for determining periodontal prog-
nosis after orthodontic treatment of BIMC. In contrast,
PIMC periodontal outcomes appear to be unchanged by
surgical-orthodontic treatment with open technique.
Conflict of interest
The authors declare no conflict of interest. This study received no
external funding.
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