POINT/COUNTERPOINT
Palatally impacted canines: The case for
preorthodontic uncovering and autonomous
eruption
David P. Mathewsa and Vincent G. Kokichb
Seattle, Wash
I
mpacted teeth are often encountered during the
diagnosis and treatment of malocclusions in
adolescent orthodontic patients. After the third
molars, the most commonly impacted tooth is the
maxillary canine with an incidence of 1% to 3%, which
varies depending on the ethnicity of the sample
population.1-8 Although the canine crown can be im-
pacted either labially or palatally, it is more frequently
positioned in the palate.
Although most palatally displaced canines can be
positioned orthodontically in the alveolus, several
problems might accompany the management of these
ectopically positioned teeth. First, the overall length of
orthodontic treatment is increased when the patient
has a palatal impaction.9-11 Second, there are often
problems of alveolar bone loss around the adjacent lat-
eral incisor and premolar as well as the canine.12-14 Third,
root resorption of the adjacent lateral incisor is a com-
mon aftermath of treating a palatally impacted ca-
nine.15,16 Finally, gingival recession on the labial or
palatal surfaces can accompany the treatment of these
teeth.17
All of these potential problems can result in an
increased risk of litigation between the orthodontist
and an unhappy patient. In the United States, lawsuits
for mismanagement of palatally impacted canines
rank second in frequency, just behind periodontal
problems developing during the orthodontic treatment
of adults. Why do these problems exist? Is it because
of the orthodontic mechanics? Is it because of the
surgical technique of uncovering these teeth? Or is it
a combination of factors?
From the University of Washington, Seattle.
a
Affiliate associate professor, Department of Periodontology.
b
Professor, Department of Orthodontics.
Reprint requests to: Vincent G. Kokich, 1018 Corona Dr, Tacoma, WA 98466;
e-mail, vgkokich@u.washington.edu.
Am J Orthod Dentofacial Orthop 2013;143:450-9
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.02.011
450
OPTIONS FOR TREATING PALATALLY IMPACTED
CANINES
Several methods are proposed in the literature to
manage and treat palatally impacted canines. Some of
these methods have been described as interceptive and
do not require surgical uncovering. These include extrac-
tion of maxillary deciduous canines at the appropriate
time and in the appropriate situation,18,19 use of cervical
headgear to create maxillary arch length,20 use of a palatal
expander to increase maxillary arch length,21,22 and use of
brackets and archwires to create extra space in the alveolar
ridge during the mixed dentition so that the maxillary ca-
nine will erupt naturally.23,24
There is some evidence in the literature that these in-
terceptive tactics will work in the appropriate situation.
However, in many clinical situations, these techniques
are not appropriate, and the palatally impacted canine
must be uncovered surgically and moved into position
orthodontically. There are 2 strategies for sequencing
the orthodontics and the surgical uncovering.
One strategy is to place brackets on the maxillary
teeth, create sufficient space for the impacted canine,
and then surgically uncover the impacted tooth. After
a short healing period of a few weeks, traction is placed
on the tooth, and it is moved toward the alveolar ridge.
The other strategy is to uncover a palatally displaced
canine before placing orthodontic appliances and allow
the tooth to erupt autonomously into the palate.25-28 Usu-
ally 6 to 9 months later, these teeth will have erupted suf-
ficiently so that orthodontic appliances can be placed, and
the canines can be moved into the dental arch.
The purpose of this “Point/counterpoint” feature
is to debate the advantages and disadvantages of
these 2 techniques: exposure and early traction vs
preorthodontic uncovering and autonomous eruption
of palatally impacted canines.
DISADVANTAGES OF UNCOVERING AND EARLY
TRACTION
When surgical exposure and early traction are
planned, maxillary brackets are placed, and the teeth
452 Point

are aligned. After about 6 months of orthodontics, the periodontal ligament to develop around a recently
surgery is performed to uncover the crown of the uncovered tooth in an adult.
canine. Typically, this involves elevating a flap,
removing bone over the crown, placing an attachment BENEFITS OF PREORTHODONTIC UNCOVERING
on the tooth, replacing the flap to cover the exposed AND AUTONOMOUS ERUPTION
bone, and then using an elastomeric chain or spring
The strategy of preorthodontic uncovering and
to move the tooth toward the edentulous ridge distal
autonomous eruption avoids some of the above-
to the lateral incisor.
mentioned unfavorable sequelae and produces several
One disadvantage of this technique is that the
additional benefits for the patient. First, the length of
crown of the canine is still buried beneath the palatal
time that the patient wears orthodontic appliances is
bone. When a force is placed on the canine, it pulls
reduced. If the canine is uncovered before brackets
the crown against the bone. This places enamel in
are placed, it typically takes about 6 to 9 months in
direct contact with the bone. Enamel does not resorb
an adolescent for the canine cusp to erupt into the
bone physiologically. There are no cells along the
palate to the level of the maxillary occlusal plane.
enamel surface that promote resorption of the palatal
Therefore, there is no need to place brackets on the
bone. The bone eventually does resorb, most likely
maxillary teeth until the canine has fully erupted into
because of pressure necrosis. However, as the crown
the palate. This delay in placing maxillary brackets
moves through the bone, it does not deposit bone
would reduce the time in appliances for patients.
behind in its path. This can result in the creation of
Second, if the canine has erupted out of the palatal
an alveolar defect distal to the lateral incisor and on
bone, when the tooth is moved laterally toward the
the mesial and distal sides of the canine. This problem
dental arch, the root, not the
has been documented in sev-
crown, will be moving
eral previous investigations,
We believe that the preorthodontic through the bone. Roots
which showed evidence of
uncovering and autonomous move through bone physio-
bone loss adjacent to
logically, leaving bone behind
palatally impacted canines eruption technique is a safe and
the roots as they progress lat-
that were treated in this predictable option for treating
29-32 erally toward the dental arch.
manner.
A second disadvantage of
palatally impacted maxillary Third, when the canine is
uncovered before orthodontic
early traction of a palatally canines in adolescents and adults.
treatment, the crown of the
displaced canine after surgical
tooth tends to erupt palatally
uncovering is the potential for root resorption on the
and away from the root of the lateral incisor. Therefore,
lingual aspect of the lateral incisor. When a canine
there is a reduced risk of root resorption caused by the
crown is moved into close contact with the lateral inci-
canine crown passing too near the lateral incisor root.
sor root, root resorption is likely. Previous researchers
Fourth, if one waits for the tooth to erupt, then it is
have noted a higher incidence of lateral incisor root re-
highly likely that a functioning periodontal ligament
sorption when canines were moved into the dental arch
has been established. After all, it is the periodontal
in this manner.15,16
ligament that ensures the processes of resorption and
A third potential disadvantage with surgical
deposition on the pressure and tension sides of the
uncovering and early traction is that the canine might
root, respectively, during orthodontic tooth movement.
not respond initially to the orthodontic force. Why
would this occur? When a tooth has been buried in
the alveolus for an extended time, such as an impacted SURGICAL PROCEDURE AND TIMING
tooth in an adult, the tissue surrounding the root can Palatally displaced canines can be classified as simple
undergo disuse atrophy. We assume that, as soon as impactions when they are not too deeply embedded in
any tooth is uncovered surgically, it will have the alveolus and the tip of the impacted canine is near
a functional periodontal ligament that will respond to the cementoenamel junction of the lateral or central in-
an orthodontic force. Perhaps this is true in children, cisor. These teeth can be uncovered with a soft-tissue
but it is not likely to be true in adults. Early traction punch technique or a flap. If the impacted canine were
in adults often results in little or no movement, and superficial and coronally positioned, with a prominent
the orthodontist might assume that the canine is bulge in the palate, the soft-tissue punch procedure
ankylosed. It can take several months for a functional might be appropriate. There is usually no bone covering

April 2013  Vol 143  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
454
these canines, so soft-tissue removal could be all that is
required. A dressing can be placed if there is concern
about tissue overgrowth.
When the canine is more deeply embedded and
apically positioned, flap access facilitates the surgical un-
covering. This requires flap reflection and complete bone
removal from the coronal aspect of the tooth. If the
deciduous canines are present, they are extracted at
the time of the uncovering procedure. A full-thickness
palatal flap is reflected from the premolar up to the mid-
line. A collar of gingiva, 2 to 3 mm wide, can be left
around the palatal aspects of the lateral and central inci-
sors. A curette or surgical round bur is used to locate the
impacted tooth by gently removing the encasing bone.
The crown of the tooth is exposed. Removal of the follicle
around the periphery is not necessary and might increase
the bleeding during the procedure. This will complicate
the surgery if bracket placement is necessary.
At this point, experience will help in the decision to
bond a bracket to help retain a dressing. If the tooth is
not deeply embedded in the palatal bone, and the
surgeon believes that it will not cover over with tissue
during the healing process, then a bracket and dressing
are not needed. Before flap closure, the area of the flap
over the impacted tooth is scalloped, so that it leaves
the tooth exposed after the flap is sutured.
If the tooth were more deeply embedded in the
bone, a cleat should be placed that would retain
a dressing more predictably. The flap is scalloped and
sutured, and a light-cured periodontal dressing is
attached to the cleat. The dressing will ensure that
the tissue does not recover the exposed tooth. This
dressing can be left for up to 5 months, if necessary.
During this time, the tooth, without orthodontic
assistance, will start erupting above the surface of the
palatal tissue. The dressing can then be removed.
RISKS OF PREORTHODONTIC UNCOVERING AND
AUTONOMOUS ERUPTION
One benefit of the preorthodontic uncovering and
autonomous eruption technique is that it can be
performed early, during the mixed dentition, so that
by the time all remaining maxillary permanent teeth
have erupted, the palatally displaced canine will be fully
erupted into the palate. However, performing a surgical
procedure on a child of 10 or 11 years of age can be
a challenge because they are apprehensive. Therefore,
premedication could be indicated for some of these
younger patients.
Another potential disadvantage of this technique is
that an open wound remains after the surgery.33 The
April 2013  Vol 143  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Point
palatal tissue is removed to permit the canine to erupt
autonomously. However, there is typically minimal
morbidity from this procedure compared with a closed
approach.34,35 To enhance patient comfort, a light-
cured dressing can be placed over the wound and
attached to a bonded cleat on the cingulum of the
canine. This dressing minimizes the potential for pain
after the surgery.
A third possible problem with this strategy is that
the surgeon might not remove sufficient bone from
around the crown of the tooth. In this situation, the
canine crown will meet resistance of the surrounding
palatal bone and prevent autonomous eruption. This
could require further surgery to remove additional
bone. Surgeons should be informed that sufficient
bone must be removed to allow the canine crown to
erupt without impediment.
A fourth potential problem is that after the canine
crown begins to erupt into the palate, the patient
must clean the tooth regularly to remove plaque to
prevent decalcification and caries. In reality, this
potential problem also exists if the tooth were being
actively moved orthodontically. Therefore, in both
situations, adolescent patients must often be reminded
to clean the palatally displaced canine during their
routine oral hygiene.
As mentioned previously, a problem with uncover-
ing and early traction is that bone loss occurs adjacent
to the previously impacted tooth. It is not yet clear
whether preorthodontic uncovering and autonomous
eruption produces a better periodontal response after
orthodontic treatment compared with uncovering and
early traction. We evaluated the periodontal status
of 22 patients treated with this technique and found
that the periodontal response is slightly better.
However, we still found some evidence of attachment
loss adjacent to the previously impacted canines.36 A
randomized clinical trial is needed to compare both
techniques in a controlled study. However, these
types of studies take many years to accomplish
successfully.37,38
Finally, a sixth potential problem is that the
eruption process typically takes longer in adults. In
fact, it is not uncharacteristic for a palatally impacted
canine in an adult to take nearly a year to fully erupt
after uncovering. Why is the process so delayed in
adults? A palatally displaced maxillary canine in
a 35-year-old has been encased in bone for over 20
years. It is highly likely that the tissue surrounding
the root of that tooth will not be as responsive to
autonomous eruption immediately after uncovering
as is typically seen in adolescents. This does not mean
456
that the tooth will not erupt. We believe that the
surgical uncovering process signals the tissue
surrounding the root to gradually be transformed
into a functioning periodontal ligament that will
permit autonomous eruption with time. In fact, we
have not encountered a tooth that would not erupt
autonomously after uncovering, even in adults.
CONCLUSIONS
We believe that the preorthodontic uncovering and
autonomous eruption technique is a safe and predict-
able option for treating palatally impacted maxillary
canines in adolescents and adults. Our research
and clinical experience show that this technique
provides significant benefits to the orthodontist and
the patient with a minimal risk of morbidity or failure
of eruption.
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