Received: 15 January 2018 Revised: 2 June 2018 Accepted: 3 June 2018

DOI: 10.1002/JPER.18-0034

ORIGINAL ARTICLE

Labially impacted maxillary canines after the closed eruption

technique and orthodontic traction: A split-mouth comparison
of periodontal recession

Ji Yeon Lee1 ∗ Yoon Jeong Choi2,5 ∗ Seong-Ho Choi3 Chooryung J. Chung4

Hyung-Seog Yu2 Kyung-Ho Kim4

1 Private practice
Abstract
2 Department of Orthodontics, The Institute

of Craniofacial Deformity, Yonsei University

College of Dentistry, Seoul, Korea
3 Department of Periodontology, Research
Institute for Periodontal Regeneration, Yonsei
University College of Dentistry
4 Department of Orthodontics, Gangnam
Severance Dental Hospital, The Institute of
Craniofacial Deformity, Yonsei University
College of Dentistry
5 Department of Mechanical engineering,
College of Engineering, Yonsei University,
Seoul, Korea
Correspondence
Kyung-Ho Kim, Professor and Department
Chair, Department of Orthodontics, Gangnam
Severance, Hospital, Yonsei University, 211
Eonju-ro, Gangnam-gu, Seoul 06229, Korea.
Email: khkim@yuhs.ac
∗ Contributed equally to this work.
Background: Labially impacted maxillary canines may lack periodontal tissue after
orthodontic traction. This study evaluated the periodontal status of labially impacted
maxillary canines after the closed eruption technique followed by orthodontic traction
and investigated pretreatment variables affecting periodontal changes.
Methods: Patients with one labially impacted maxillary canine (impaction group)
and one contralateral normal canine (control group) were selected retrospectively.
Maxillary canine pretreatment variables (angle, depth, sector, and Nolla stage) were
determined from initial panoramic radiography. Periodontal outcomes including sul-
cus probing depth, bone probing depth, keratinized gingiva width (KGW), attached
gingiva width (AGW), clinical crown length (CCL), cemento-enamel junction to alve-
olar crest (CEJ-AC) distance, root length, and bone support were measured from
radiographic and clinical examinations after treatment and compared between the two
groups. Pretreatment variables affecting the periodontal outcomes were determined
using linear regression analyses.
Results: Fifty-four patients (21 males and 33 females; mean age, 12.85 years) were
enrolled. The KGW, AGW, and root length were shorter; the CCL and CEJ-AC dis-
tance were longer; and the bone support on the interproximal sides was less in the
impaction group than in the control group (P < 0.05). The root length was shorter
with higher Nolla stages and the distal alveolar crest was lower with deep and mesially
angulated impaction (P < 0.01).

Conclusions: After the closed eruption technique, impacted canines exhibited slight
but clinically insignificant periodontal recession compared with the contralateral nor-
mal tooth. The root developmental stage and pretreatment depth and angle may
influence periodontal recession.

KEYWORDS
cuspid, periodontal index, tooth

J Periodontol. 2019;90:35–43. wileyonlinelibrary.com/journal/jper © 2018 American Academy of Periodontology 35

36
The maxillary canines, except for the third molars, are most
frequently impacted with a prevalence ranging from 1% to
3%.1 When considering the periodontal implications of surgi-
cal exposure and subsequent alignment of an impacted maxil-
lary canine, it is necessary to differentiate between a palatally
and labially impacted canine. Labial impaction is more chal-
lenging to manage because the labial alveolar bone is usually
insufficient for the impacted canine to move over the adja-
cent tooth.2–4 Moreover, a labially impacted canine is cov-
ered by thin oral mucosa, which indicates that there is a thin
alveolar plate that is susceptible to dehiscence and gingival
recession.5,6
The apically positioned flap technique3 and closed erup-
tion technique7 are commonly used to uncover a labially
impacted canine surgically.8 The apically positioned flap tech-
nique is used to retain the attached gingiva around the tooth
when the tooth is impacted below the mucogingival junc-
tion. It has the advantages of less invasiveness, provides eas-
ier control of the tooth, requires a shorter treatment time,
and retains attached gingiva, which prevents marginal bone
loss and gingival recession.4,9 However, if the location of the
impacted tooth is above the mucogingival junction, an api-
cally positioned flap may cause crown instability and rein-
trusion of the tooth after orthodontic treatment because the
repositioned gingiva stretch due to tooth movement, which
may cause orthodontic relapse after removal of the orthodon-
tic appliance.8,9 In the closed eruption technique, the crown
of the impacted tooth is exposed, an orthodontic button con-
nected to an extension wire is attached, the flap is repositioned
over the crown, and sutures along with the wire emerge from
the center of the alveolar ridge. Therefore, the closed erup-
tion technique is appropriate for uncovering a tooth impacted
deep in the alveolar bone because it encourages the tooth to
erupt toward the center of the alveolar ridge.7,9,10 Although it
is difficult to select an accurate force vector with the closed
eruption technique, it exhibits less vertical relapse and more
esthetic results because of less gingival scarring.4,9
Surgical exposure and orthodontic alignment aim to obtain
esthetically and functionally successful outcomes, which
depend on healthy periodontium surrounding the tooth.
Previous studies on periodontal structures after the closed
eruption technique have reported conflicting results.4,10
Some believe that the closed eruption technique can yield the
best esthetic and periodontal outcomes because it resembles
natural tooth eruption,10 while others have reported that it
resulted in adverse periodontal responses.4 However, these
studies presented only gingival measurements with limited
numbers of subjects or mentioned the tendencies of the
periodontal responses; this may be because there has been no
well-designed study that investigated periodontal status after
performing the closed eruption technique.11
LEE ET AL.
Even though initial radiographic features have been inves-
tigated as prognostic indicators for periodontal consequences
after the apically positioned flap procedure, to our knowledge,
only one study has assessed these associations after the closed
eruption technique and did not differentiate labial impaction
from palatal impaction.12 Therefore, this study was conducted
to evaluate the periodontal outcomes of labially impacted
maxillary canines after the closed eruption technique and
to identify pretreatment radiographic indicators influencing
these changes.
1 M AT E R I A L S A N D M E T H O D S
1.1 Patients
Patients who visited the Department of Orthodontics at
Gangnam Severance Dental Hospital from January 2002 to
June 2009 and had a unilateral labially impacted maxillary
canine were retrospectively evaluated in this study. The inclu-
sion criteria were surgical uncovering of the impacted canine
using the closed eruption technique; existence of a normally
positioned contralateral maxillary canine, which was served
as a control; the presence of a panoramic radiograph before
treatment (T0); and the availability of treatment records after
orthodontic treatment (T1) including a periapical radiograph
and periodontal examinations for both the impacted and con-
tralateral canines. A periapical radiograph was obtained with a
0.016 × 0.022-inch stainless steel guide wire 10 mm in length
to compensate for changes in the axis of the X-ray beam. Peri-
odontal examinations included sulcus probing depth (SPD),
bone probing depth (BPD), keratinized gingiva width (KGW),
and clinical crown length (CCL). The exclusion criteria were
as follows: a missing tooth adjacent to the canine, open con-
tacts against the adjacent lateral incisor or first premolar at T1,
considerable distortion between the right and left sides on the
initial panoramic radiograph, and a gingival index (GI) score
of 2 or 3.13
One periodontist (Ik-Sang Moon, Department of Periodon-
tology, Gangnam Severance Dental Hospital, Yonsei Univer-
sity College of Dentistry, Seoul, Korea) performed all closed
eruption technique surgical procedures and one orthodontist
(KHK) performed the orthodontic treatments for the impacted
canines. The surgical procedure was performed as described
in previously, and orthodontic traction was performed to guide
the tooth's movement toward the center of the alveolar ridge
(Figure 1).
The study protocol was approved by the hospital's institu-
tional review committee for human participants (No. 3-2014-
0087) and was conducted in accordance with the Helsinki
Declaration of 1975, as revised in 2013.
LEE ET AL.
FIGURE 1 A clinical case demonstrating treatment progress. The impacted maxillary right canine is moved by orthodontic traction following
the closed eruption technique
1.2 Measurements
Regarding pretreatment variables, we measured four maxil-
lary canine parameters on the initial panoramic radiographs
as seen in 2 the Nolla stage to indicate tooth developmental
stages, perpendicular distance from the cusp tip to the occlusal
plane (d-depth), canine angulation (𝛼-angle), and mesio-distal
displacement (s-sector).12,14,15 The occlusal plane was drawn
by connecting the maxillary first molar and central incisor
on each side. The canine angulation was defined as the angle
between the canine's long axis and bicondylar line, which was
drawn by connecting the uppermost points of the right and
left condyles. The mesio-distal displacement of the canine
was defined by dividing it into four sections according to the
location of the canine cusp tip relative to the adjacent lateral
incisor (Figure 2B).
Post-treatment periodontal outcomes were assessed
from radiographic and clinical examinations that had been
performed≈1 month after removal of the orthodontic appli-
ance. On a periapical radiograph, the cemento-enamel
junction (CEJ), alveolar crest (AC), and root apex of the
canine were identified. After correcting for magnification
errors by using a 10-mm guide wire, the mesial and distal
distances between the CEJ and AC (CEJ-AC) were measured
parallel to the long axis of the tooth. Root length was
measured as the perpendicular distance from the root apex
to a line connecting the mesial and distal CEJs (Figure 2C).
The (distance between the apex and AC)/root length ratio
was calculated to determine the percentages of bone support
on the mesial and distal sides. A software program∗ was used
for all measurements.
Clinical examinations included the GI, SPD, BPD, CCL,
KGW, and attached gingiva width (AGW), which were
∗ ImageJ, National Institutes of Health, Bethesda, MD
37
performed on all patients with an impacted tooth by using a
periodontal probe† based on the clinical protocol of the study
hospital. The SPD and BPD were measured in the mesio-
buccal, mid-buccal, disto-buccal, mesio-lingual, mid-lingual,
and disto-lingual regions of the canine. For BPD measure-
ments, the probe tip was forced through the connective tissue
under local anesthesia until definite resistance was obtained.16
The CCL was measured on the buccal tooth surface from
the incisal edge to the deepest point on the curvature of
the vestibular gingival margin parallel to the long axis of the
tooth. The KGW was measured at the mid-buccal point as the
distance from the free gingival margin to the mucogingival
junction and the AGW was calculated by subtracting the SPD
at the mid-buccal point from the KGW.
1.3 Statistical analysis
All statistical analyses were performed using statistical soft-
ware.‡ The impacted canines (impaction group) and contralat-
eral normal canines (control group) were compared using
paired t-tests. McNemar tests were used to determine the sig-
nificance of differences in the s-sector and the Nolla stage
of tooth development between the two groups. Simple and
multiple linear regression analyses were conducted to deter-
mine if the pretreatment variables influenced changes in the
post-treatment periodontal outcomes. The variance inflation
factor revealed that there was no multicollinearity with the
covariates.
One examiner performed all measurements. To evaluate
intraexaminer reliability, the examiner repeated all measure-
ments for 25 randomly selected patients within a 1-month
† N22T, devemed GmbH, Tuttlingen, Germany
‡ SPSS 20.0, IBM, Armonk, NY
38 LEE ET AL.

FIGURE 2 An initial panoramic radiograph to define the canine position before treatment (A and B) and a schematic drawing of
measurements on periapical radiographs after treatment (C). A, A schematic drawing defining the d-depth and 𝛼-angle. The bicondylar line connects
the uppermost points of the condyles; the occlusal plane connects the maxillary central incisor and first molar on each side. The 𝛼-angle is the angle
formed by the intersection of the bicondylar line and long axis of the canine, and the d-depth is the perpendicular distance from the canine cusp tip to
the occlusal plane. B, the modified s-sector determined by the location of the canine cusp tip relative to the adjacent lateral incisor. Three lines were
used to divide the region into four sections: the long axis of the lateral incisor and two tangential lines to the mesial and distal heights of the contour
of the lateral incisor, defined as sectors I, II, III, and IV. C, measurements of the distance from the cemento-enamel junction (CEJ) to the alveolar
crest (AC) on the mesial and distal sides (blue arrow) and root length, which is the perpendicular distance from the root apex to a line connecting the
mesial and distal CEJs (red arrow)

interval and the intraclass correlation coefficient (ICC) was
determined. A P-value < 0.05 was considered statistically
significant.
2 RESULTS
One-hundred-thirty-eight patients with a unilateral labi-
ally impacted maxillary canine were considered for enroll-
ment. The patients included in this study were 54 patients
selected consecutively (21 males and 33 females; mean age,
12.85 ± 3.50 years). The average duration of orthodontic trac-
tion for the impacted canine was 12.74 ± 7.74 months and
the average duration of orthodontic treatment (from T0 to T1)
was 30.30 ± 10.78 months. Before treatment, the impaction
and control groups did not exhibit a significant difference in
the Nolla stage (P > 0.05). However, the impaction group
had smaller 𝛼-angle and larger d-depth values than the control
group (P < 0.05), which indicates greater horizontal and api-
cal positioning of the impacted canine. The s-sector exhibited
a significant difference between the two groups (P < 0.05);
the cusp tips in the impaction group were positioned more
mesially than in the control group (Table 1). The ICC showed
high reliability for intraexaminer measurements (ICC > 0.93).
There were significant differences in post-treatment peri-
odontal parameters between the impaction and control groups,
except for SPD and BPD (Table 2, P < 0.05). On periapical
examination, the impaction group exhibited a longer CEJ-AC
distance, shorter root length, and lesser bone support than the
control group (P < 0.05). The SPD and BPD values were sim-
ilar between the two groups (P > 0.05), except for the disto-
lingual BPD. In the impaction group, the CCL was longer
(P < 0.01) and the KGW and AGW were significantly shorter
than in the control group (P < 0.05).
LEE ET AL. 39

TABLE 1 The Nolla stages and pretreatment positions of the maxillary canines (n = 54)
Nolla stage
Group 7 8 9 10 P value*
Impaction group 8 (15%) 15 (28%) 22 (41%) 9 (16%) 0.254
Control group 2 (4%) 11 (20%) 27 (50%) 14 (26%)
s-sector
Group I II III IV P value*
Impaction group 13 (24%) 14 (26%) 8 (15%) 19 (35%) <0.0001
Control group 43 (80%) 10 (19%) 1 (1%) 0 (0%)
Group 𝜶-angle (◦ ) P value† d-depth (mm) P value†
Impaction group 62.14 ± 22.3 <0.0001 15.03 ± 4.49 <0.0001
Control group 86.99 ± 8.74 3.62 ± 5.48
Nolla stage and s-sector are presented as numbers (percentages). Nolla stage 7, one third of root completed; 8, two third of root completed; 9, root almost completed, but
open apex; 10, root apex completed. 𝛼-angle and d-depth are presented as mean ± SD. 𝛼-angle, the angle between the bicondylar line and the long axis of the canine;
d-depth, the perpendicular distance from the canine cusp tip to the occlusal plane.
*McNemar test
† Paired t-tests were performed to compare the two groups.

TABLE 2 Comparisons of post-treatment periodontal outcomes between the impaction and control groups
Variables Impaction group Control group P value
CEJ-AC (mm) Mesial 2.58 ± 0.88 1.69 ± 0.62 0.002†
Distal 2.29 ± 0.89 1.46 ± 0.46 0.002†
Root length (mm) 15.10 ± 2.93 16.88 ± 3.00 0.020*
Bone support (%) Mesial 82.02 ± 8.81 89.33 ± 4.81 0.002†
Distal 84.33 ± 4.81 93.12 ± 4.54 0.002†
Sulcus probing depth (mm) Mesio-buccal 2.46 ± 0.75 2.32 ± 0.43 0.166
Mid-buccal 1.73 ± 0.50 1.53 ± 0.63 0.400
Disto-buccal 2.54 ± 0.58 2.50 ± 0.62 0.570
Mesio-lingual 2.66 ± 0.67 2.41 ± 0.54 0.060
Mid-lingual 2.05 ± 0.50 1.95 ± 0.59 0.232
Disto-lingual 2.68 ± 0.72 2.63 ± 0.58 0.580
Bone probing depth (mm) Mesio-buccal 4.42 ± 0.98 4.16 ± 0.66 0.062
Mid-buccal 3.27 ± 0.84 3.19 ± 0.73 0.484
Disto-buccal 4.30 ± 0.55 4.31 ± 0.68 0.907
Mesio-lingual 4.45 ± 0.80 4.21 ± 0.63 0.052
Mid-lingual 3.82 ± 0.71 3.60 ± 0.61 0.050
Disto-lingual 4.72 ± 0.95 4.24 ± 0.56 0.040*
Clinical crown length (mm) 9.97 ± 1.19 8.85 ± 1.05 0.002†
Keratinized gingiva width (mm) 3.51 ± 1.22 3.94 ± 0.97 0.040*
Attached gingiva width (mm) 1.78 ± 1.22 2.41 ± 1.00 0.008†
Data are presented as mean ± SD.
CEJ, cemento-enamel junction; AC, alveolar crest. Root length indicates the perpendicular distance from the root apex to a line connecting the mesial and distal CEJs.
Bone support is calculated by dividing apex-AC distance by apex-CEJ distance.
Paired t-tests were used to compare the two groups, and Bonferroni corrections were performed to adjust type I error.
*P < 0.05; † P < 0.01.

A simple regression analysis revealed that the d-depth and
𝛼-angle had significant relationships with the post-treatment
CEJ-AC distance and bone support on the distal side (Table 3,
P < 0.05). The d-depth also had a significant relationship
with the disto-buccal BPD (P < 0.05). A multiple regression
analysis demonstrated that the s-sector was not related to the
periodontal outcomes (Table 4, P > 0.05). The Nolla stage
negatively affected root length (P < 0.05), which indicates
that the root length is likely to be short, as the root of the
impacted canine is more developed. The d-depth and 𝛼-angle
40 LEE ET AL.

TABLE 3 Standardized coefficients from the simple linear regression analysis for factors affecting post-treatment periodontal parameters
Variables Nolla stage d-depth 𝜶-angle s-sector
CEJ-AC (mm) Mesial −0.007 0.043 −0.012 0.097
Distal −0.164 0.085† −0.017† 0.025
Root length (mm) 0.379 −0.033 −0.002 −0.088
Bone support (%) Mesial 0.002 −0.004 0.001 −0.009
Distal −0.002 −0.006† 0.001* −0.005
Sulcus probing depth (mm) Mesio-buccal 0.046 −0.009 0.011 −0.043
Mid-buccal 0.075 0.014 −0.001 0.016
Disto-buccal 0.042 0.017 −0.001 −0.051
Mesio-lingual 0.042 0.026 −0.002 0.085
Mid-lingual 0.102 −0.003 0.003 0.089
Disto-lingual −0.046 0.042 −0.005 0.016
Bone probing depth (mm) Mesio-buccal 0.016 0.024 0.012 0.022
Mid-buccal 0.021 0.052 −0.001 0.065
Disto-buccal 0.129 0.046* −0.005 0.088
Mesio-lingual 0.172 0.035 −0.002 0.058
Mid-lingual 0.117 0.013 0.007 −0.085
Disto-lingual 0.079 0.026 0.001 −0.102
Clinical crown length (mm) −0.024 −0.007 −0.009 −0.235
Keratinized gingiva width (mm) 0.038 0.028 −0.015 0.273
Attached gingiva width (mm) −0.133 0.047 −0.010 0.215
CEJ, cemento-enamel junction; AC, alveolar crest. Root length indicates the perpendicular distance from the root apex to a line connecting the mesial and distal CEJs.
Bone support is calculated by dividing apex-AC distance by apex-CEJ distance.
*P < 0.05; † P < 0.01.

TABLE 4 Standardized coefficients from the multiple linear regression analysis for factors affecting post-treatment periodontal parameters
Variables Nolla stage d-depth 𝜶-angle s-sector
CEJ-AC (mm) Mesial −0.109 0.027 0.116 0.026
Distal −0.019 0.089‡ −0.065† −0.084
Root length (mm) −1.380† −0.084 −0.279 0.142
Bone support (%) Mesial 0.032 −0.003 −0.012 0.001
Distal 0.001 −0.054† 0.031† 0.009
Sulcus probing depth (mm) Mesio-buccal 0.140 0.035 0.017 −0.012
Mid-buccal 0.059 0.019 0.002 0.002
Disto-buccal 0.194 0.046 0.006 −0.025
Mesio-lingual 0.024 0.022 0.001 0.025
Mid-lingual 0.131 0.013 0.007 0.117
Disto-lingual 0.065 0.056 0.003 −0.029
Bone probing depth (mm) Mesio-buccal 0.175 0.094* 0.026 0.022
Mid-buccal 0.067 0.092 0.011 0.012
Disto-buccal 0.209 0.072* 0.006 0.038
Mesio-lingual 0.171 0.038 0.003 −0.050
Mid-lingual 0.118 0.076* 0.016 −0.180
Disto-lingual 0.207 0.076 0.010 −0.175
Clinical crown length (mm) −0.219 0.028 0.008 −0.225
Keratinized gingiva width (mm) 0.154 0.010 −0.007 0.296
Attached gingiva width (mm) 0.101 0.065 0.005 0.205
CEJ, cemento-enamel junction; AC, alveolar crest. Root length indicates the perpendicular distance from the root apex to a line connecting the mesial and distal CEJs.
Bone support is calculated by dividing apex-AC distance by apex-CEJ distance.
*P < 0.05; † P < 0.01; ‡ P < 0.001.
LEE ET AL.
affected the CEJ-AC distance and bone support on the distal
side (P < 0.05); the d-depth affected the mesio-buccal, disto-
buccal, and mid-lingual BPDs (P < 0.05). This indicates that
the ACs are reduced when the canine is impacted deeply
and that the distal AC is likely to be resorbed as it is angled
mesially.
3 DIS CUSSI O N
After performing the closed eruption technique for labially
impacted maxillary canines, the canines exhibited a longer
CCL, shorter AGW, shorter KGW, shorter root length, less
bone support, and lower AC on the mesial and distal sides
compared with the normally positioned contralateral canines.
The comparison indicates that impacted canines had greater
gingival recession, less attachment, and more coronally
positioned mucogingival junctions. The post-treatment root
length was influenced by the pretreatment Nolla stage, and the
AC level and bone support on the distal side were influenced
by the pretreatment depth and angle of the impacted canine.
The pretreatment impaction depth also affected the BPD in
some areas. The mesio-distal position of the impaction did not
influence post-treatment periodontal status.
For a palatally impacted canine, the surgical technique is
not a determining factor because there is a sufficient amount
of attached gingiva.11 However, for a labially impacted
canine, the surgical technique is critical because it affects
the amount of attached gingiva, which determines the final
periodontal status.3 Among three techniques to expose a
labially impacted canine (an apically positioned flap, closed
eruption, and excisional exposure),8 excisional exposure is
rarely performed these days. It had been performed to expose
a labially impacted canine but resulted in more recession
and a shorter KGW than in untreated controls.11,17 Apically
positioned flaps were reported to have SPD and AGW values
comparable with those of untreated canines.11
After the closed eruption technique, the impacted canine
had a shorter AGW and greater recession compared with the
untreated control, although its eruption was guided toward
the center of the alveolar ridge. A surgical procedure that
simply reflected a flap to expose the impacted canine and the
tensional force in the gingival fibers caused by tooth move-
ment might have compromised the attachment, considering
that there were no pretreatment radiographic variables that
correlated with the CCL, KGW, or AGW. De-rotation of the
canine after eruption could also result in a reduced AGW
and increased CCL18 because the blind traction of the closed
eruption technique might cause the canine to erupt in a rotated
position. The AGW in the impaction group was <2 mm,
which was reported as the minimal amount required to main-
tain periodontal health.19 A deficient AGW may predispose
the patient to periodontal inflammation and a subsequent loss
41
of periodontal support,3,20–22 although recent studies suggest
that even smaller amounts of KGW and AGW would be
sufficient to maintain periodontal health.23–25
The CEJ-AC distance was 0.82 to 0.89 mm greater and the
root length was 1.78 mm shorter in the impaction group than
in the control group, which resulted in less bone support in the
impaction group. The interproximal alveolar bone loss might
be attributed to orthodontic tooth movement. Although a light
force of 20 to 30 g is enough to erupt the tooth, a greater
force exceeding the optimal force level is likely to be delivered
to reposition the impacted tooth.26 Consequently, the adja-
cent compression side, which is the distal side in the case of
a mesio-angulated impacted canine, would undergo hyalin-
ization in the periodontal ligament and subsequent alveolar
bone resorption. On the contrary, the alveolar bone apposi-
tion would occur on the tension side, which is the mesial side
in the same situation. However, orthodontic tooth movement
over a long distance might make the alveolar bone sensitive to
periodontal inflammation,27 which resulted in a longer CEJ-
AC distance in the impaction group than in the control group,
even on the mesial side.
A multiple regression analysis confirmed the findings
that the 𝛼-angle and d-depth influenced the distal CEJ-AC
distance. As the impacted canine is angled mesially and
impacted deeply, the distal AC, which is on the compression
side, is likely to be resorbed. This consequently leads to less
bone support on the distal side. The d-depth also affected the
mesio-buccal, disto-buccal, and mid-lingual BPDs, which
indicates that the buccal and lingual ACs are lower when
the canine is impacted deeply. Root length was negatively
influenced by the Nolla stage. This might be because apical
root resorption is less vulnerable when the root apex is not
completely closed.28,29
This study used a split-mouth design, which allows each
patient to serve as his or her own control, eliminates the
need for matching criteria, and minimizes variability result-
ing from oral hygiene, the gingival biotype, and periodontal
response. Even though the common surgical techniques of an
apically positioned flap and closed eruption were not com-
pared in the present study, previous studies and the present
study demonstrate that the two techniques showed similar
findings: the impacted canine exhibited a shorter root length
and comparable probing depth compared to the untreated
tooth.9,11 However, bone probing was deeper after apically
positioned flap procedures,11,17 while the amount of attached
gingiva was less and the clinical crown was longer after
closed eruption procedures. Although the two techniques have
different indications, it seems that the periodontal tissues
of the impacted canine after orthodontic traction may not
have the same periodontium as a normal canine. Consider-
ing the progressive nature of periodontitis, clinicians need to
be careful to preserve the attached gingiva during and after
treatment.
42
The present study had some limitations. The amount of
rotation of the canine, which might influence the periodontal
responses, was not quantified. The width of the masticatory
mucosa on the alveolar ridge, which might also influence the
KGW surrounding the canine at the end of orthodontic treat-
ment, was not measured. In addition, the measurements were
performed after the comprehensive orthodontic treatment
was completed. Therefore, pretreatment periodontal condi-
tions such as differences in the pretreatment KGW between
impacted and normal canines, which would influence the
results, were not included in this study. Furthermore, indi-
vidual variation in orthodontic treatment duration including
traction of the impacted canine might also affect the peri-
odontal responses, although the influence of the orthodontic
appliance would be minimal 1 month after its removal.30,31
Moreover, because the findings were investigated on the basis
of two-dimensional images, future well-designed prospective
research using three-dimensional imaging modalities, such
as cone-beam computed tomography, might help elucidate
periodontal outcomes after closed eruption procedures and
determine pretreatment predictors.
4 CONC LU SI ON S
The closed eruption technique exhibited slightly worse peri-
odontal conditions with respect to the alveolar bone, root
length, and gingiva than the untreated control canine. How-
ever, the difference was <1 mm, most of which can be con-
sidered clinically insignificant. However, some parameters
such as the CCL and AGW require clinical follow-up over a
long duration. A higher root developmental stage and mesially
angulated deeply impacted canines may aggravate and worsen
periodontal conditions.
ACK NOW L E D G M E N T
The authors report no conflicts of interest related to this study.
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