ONLINE ONLY

A retrospective long-term pulpal,

periodontal, and esthetic, follow-up of
palatally impacted canines treated with
an open or closed surgical exposure
technique using the Maxillary Canine
Aesthetic Index
Jonathan Luyten,a,b Koenraad Grisar,b Heidi Opdebeeck,c Reinhilde Jacobs,b and Constantinus Politisb
Leuven, Belgium

Introduction: The primary objective of this study was to compare the aesthetic outcome of palatally impacted
canines treated with an open or closed surgical exposure technique using the Maxillary Canine Aesthetic Index
(MCAI) at least 1 year after debonding. Secondary objectives were set on the periodontal outcome, tooth color,
pulpal status, and self-reported contentment. Methods: The sample of this retrospective study consisted of 53
patients with an average age of 20 years and 7 months at the time of the investigation. A total of 53 canines were
investigated. All canines were aesthetically scored with the MCAI. Other outcome variables were investigated,
such as gingival inflammation, pocket probing depth, vitality, percussion sensitivity, and tooth color. All patients
received a questionnaire to evaluate their appraisal of different parameters. Results: A statistically significant
difference (P \ 0.001) was found between the groups treated with an open and closed technique in terms of
the MCAI. The closed technique scored excellent in terms of aesthetics, whereas the open technique scored
good. The closed technique had more discoloration (P \ 0.001) and a delayed response to the cold test
(P 5 0.021). In general, patients were satisfied with both techniques but considered the treatment time to be
very long. Conclusions: A closed surgical exposure of palatally impacted maxillary canines is preferred in terms
of aesthetics when measured with the MCAI. There was no difference between the 2 techniques in terms of peri-
odontal outcome. Canines treated with a closed exposure tended to have a darker color and delayed response to
cold testing. (Am J Orthod Dentofacial Orthop 2020;158:e29-e36)

M
axillary canines are the second most frequently patients.2,3 Palatal to buccal impaction ratio is 3:1.4,5
impacted teeth after the third molars.1 The Impaction is defined as the failure of tooth eruption at
overall prevalence varies between 0.9% and its appropriate site in the dental arch, within its normal
2.2%,1,2 with an incidence ratio twice as high in female period of growth.6 The maxillary canine has an impor-
tant role in occlusion, aesthetics, and continuity of the
dental arch.7
a
Department of Oral Health Sciences, Biomedical Sciences Group, KU Leuven, Different etiologic factors of maxillary canine impac-
Leuven, Belgium.
b tion such as dental discrepancy, the ectopic position of
OMFS-IMPATH Research Group, Department of Imaging and Pathology, Fac-
ulty of Medicine, KU Leuven, and Department of Oral and Maxillofacial Surgery, the tooth-germ, lack of space, lack of guidance, presence
Leuven University Hospitals, Leuven, Belgium. of hard and soft tissue pathologies, or genetic factors are
c
Private practice, Leuven, Belgium.
mentioned in the literature.5,8-11
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. Treatment options for impacted canines are (1) inter-
Address correspondence to: Jonathan Luyten, Department of Oral and Maxillo- ceptive removal of the deciduous canine, (2) surgical
facial Surgery University Hospitals Leuven, Kapucijnenvoer 33, 3000, Leuven;
exposure with or without orthodontic traction to align
e-mail, jonathanluyten2@gmail.com.
Submitted, March 2019; revised and accepted, November 2019. the malpositioned tooth, (3) autotransplantation of the
0889-5406/$36.00 permanent canine, (4) removal of the permanent canine
Ó 2020 by the American Association of Orthodontists. All rights reserved.
followed by orthodontic alignment to close the
https://doi.org/10.1016/j.ajodo.2019.11.014

e29
e30
remaining space, prosthetic or restorative treatment, or
reinforced resin-bonded bridge or implants, and (5) no
treatment.12,13
Considering surgical exposure of the impacted maxil-
lary canine, several surgical procedures and classifica-
tions have been proposed in the literature. It is
generally accepted to make a distinction between open
and closed surgical techniques. With the open tech-
nique, the gingiva above the canine is excised, and the
overlying bone layer is removed. The wound is packed
with gauze or special wound packing material to prevent
the gingiva from closing so that spontaneous eruption of
the canine can occur. Sometimes a cleat is bonded once
the tooth is exposed in order to assist eruption and
alignment further. The main drawback of this technique
is a longer postoperative sensitivity and recovery.7,14 The
major advantage is reduced surgical time as well as erup-
tion time. However, it should be considered that the
shorter eruption time in the open technique could be ex-
plained by choosing this technique when only the mu-
cosa is overlaying the impacted canine.13
The closed technique consists of a full-thickness flap
that is made above the site of impaction. The bone above
the canine is removed, and during the procedure, a
bracket or cleat is bonded to the tooth surface. Through
a gold chain or twined wire, the cleat or bracket is con-
nected to the orthodontic appliance. After the bonding,
the mucoperiosteal flap is closed and sutured in place
with the gold chain or wire exiting from the surgery
site. The main advantages are less postoperative discom-
fort, faster recovery from pain, and overall lower postop-
erative complication rates.14-16 Drawbacks are an
increased surgical time and being a more complex and
sensitive technique.
Most of the studies on impacted maxillary canines
have their focus on the periodontal outcome with
respect to probing depth, bleeding on probing, the sul-
cus bleeding index, width of the keratinized gingiva, and
attachment loss. According to the Cochrane Database of
Systematic Reviews, 3 articles with low risk of bias have
their focus on the aesthetic outcome after surgical expo-
sure and alignment of the canine.17 The Cochrane review
about this subject (Cochrane database of systematic re-
views 2017 CD006966) considers Parkin et al17 and
Smailien_e et al18 as qualitative research papers. Parkin
et al17 evaluated the aesthetics of posttreatment canines
through a panel of orthodontists and laypeople. No dif-
ference was found between the open and closed
methods.19 Smailien_e et al18 investigated tooth color,
position in the dental arch, inclination, and shape as
aesthetic criteria. They did not include gingival parame-
ters in their aesthetic appraisal. Furthermore, they did
not report whether their reporters were blinded.15
October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Luyten et al
One of the most important shortcomings in previ-
ously conducted research is that it is difficult to pool
the data and compare the outcome of the studies
because of a lack in the standardization of the parame-
ters used to evaluate the aesthetic outcome. Most pa-
rameters used by different authors focus on tooth
characteristics while ignoring gingival characteristics.
The lack of a generally accepted ranking or classification
system is mentioned in the Cochrane review by Parkin
et al.17 Outcome heterogeneity is one of the major prob-
lems in health care research.20 This problem can be
addressed by determining a Core Outcome Set, such as
an index for the aesthetic evaluation of impacted maxil-
lary canines.
The Maxillary Canine Aesthetic Index (MCAI) was
developed in response to the lack of a standardized
method of evaluating and measuring maxillary canine
aesthetics. This index can be used in both research
and clinical settings.21 It takes 12 different soft tissue
and tooth characteristics into account. Characteristics
of the gingiva are included in the overall aesthetic
evaluation of the canine. The main advantages of
the MCAI are that future results can be compared
and the system combines visible soft tissue (gingival)
and hard tissue (tooth) parameters into 1 comprehen-
sive scoring system. Additional information is pro-
vided in Table I.
Besides the aesthetic outcome as expressed by the
MCAI, we also evaluated parameters related to pulpal
characteristics such as tooth color, percussion sensitivity,
and pulpal sensitivity. The fact that in our study, the time
between the end of treatment (removal of brackets) and
the start of the investigation was almost 5 years, allowed
us to evaluate the slowly evolving pulpal changes. This
long observation time is in contrast with the relatively
short times found in the literature, where pulpal charac-
teristics after surgical orthodontic extrusion of impacted
canines are not often considered.
Subjective appraisal was included in our study
because of the increasing importance of Oral Health-
related Quality of Life and the ability to compare this
data with other current research projects.
Given the lack of standardized reporting of aesthetic
outcome (lack of Core Outcome Set) in the literature and
the short follow-up time of the pulpal status, the primary
aim of the present study was to conduct a retrospective
study to compare MCAI between 2 patient groups, one
treated with an open and the other with closed exposure
technique. Secondly, the pulpal and periodontal status
of impacted canines were investigated between those 2
groups. Thirdly, we investigated the color of the canines
treated with either an open or closed exposure
technique.
Luyten et al e31

Table I. The MCAI and parameters

Scoring

Parameters investigating PIC Absent Incomplete Complete

Mesial papilla 5 1 0
Distal papilla 5 1 0
Marginal gingiva 5 1 (\3 mm) 0 (.3 mm)
Recession (apical to MGJ) (coronal to MGJ) (no recession)
5 1 0
Marginal gingival thickness Thin – Thick
1 – 0
Mesiodistal crown angulation Distal Straight Mesial
2 1 0
Parameters comparing both canines Major discrepancy Minor discrepancy No discrepancy
Curvature of marginal gingiva 2 1 0
Soft tissue color and texture 2 1 0
Root convexity and/or bulging of the root 2 1 0
Tooth morphology 2 1 0
Vertical tooth position 2 1 0
Parameters investigating the relationship between the PIC and neighboring teeth
Buccolingual angulation crown according to the neighboring teeth 2 1 0
Total
Note. MCAI scoring21: 0-3 points 5 excellent, 4-8 points 5 good, 9-13 points 5 moderate, and $14 5 poor aesthetics.
PIC, previously impacted canine; MGJ, mucogingival junction.

MATERIAL AND METHODS

A convenience sample of 53 patients who met the
requirements was invited to participate in the study.
Forty-five of the 53 patients were recruited from a
private office circuit with access to orthodontic and peri-
odontal specialties. The remaining patients were treated
by the same orthodontic and maxillofacial surgery team
at the University Hospitals Leuven. The mean age of the
53 patients at the time of investigation was 20 years and
7 months (standard deviation [SD], 7.58 years). Twenty-
eight patients were treated with a closed technique and
25 with the open technique (see Table II). In our sample,
13 patients were male. The average time between the
time of investigation and the removal of the brackets
was 4 years and 11 months after orthodontic treatment
(SD, 3.67 years).
Exclusion criteria included systemic disorders and
congenital craniofacial deformities. Cleft lip and palate
patients were also excluded. Inclusion criteria were set
on at least 1 year after debonding of the orthodontic
appliance.
The closed treatment group consisted of 28 patients
who underwent a closed surgical exposure technique,
whereas 25 patients were treated with an open tech-
nique. The surgical procedure used in the open tech-
nique group is slightly different from the general
information presented in the introduction. The proced-
ure was performed as follows: a mucoperiosteal flap
Table II. Overall patient sample statistics and MCAI
values
Technique n Mean SD SEM P value
Closed 28 3.0000 1.90516 0.36004 0.001
Open 25 5.6400 3.23883 0.64777
SEM, standard error of the mean.
was made, the overlaying bone layer was removed, and
afterward, the flap was repositioned apically toward
the cementoenamel junction and sutured in place. An
eyelet or bracket was bonded to the tooth surface, and
the crown was covered with a wound packing material
(COE-Pak, GC, Leuven, Belgium). All canines underwent
traction after the procedure with an extrusion plate or
with a gold chain connected to a fixed appliance.
The diagnosis of impaction was made on a clinical
basis combined with a radiologic diagnosis on pano-
ramic radiography to ensure that both groups had the
same degree of severity impaction. All panoramic radio-
graphs were investigated. The analysis was performed
using Impax software (version 6.5.5.1608; Agfa Health-
Care, Mortsel, Belgium). Angulation was determined by
measuring the angle between the canine and the vertical
line parallel to the mesial surface of the central incisor.
The occlusal plane was determined by drawing a line
through the incisal edge of the central incisor and the
mesiobuccal cusp of the first molar. The distance to

American Journal of Orthodontics and Dentofacial Orthopedics October 2020  Vol 158  Issue 4
e32
Table III. Baseline canine parameters
Technique Angulation ( ) P value Distance to occlusal plane (mm)
Open 33.34 6 15.90 13.52 6 5.87
Closed 34.19 6 9.69 0.88
Note. Values are mean 6 SD.
the canine cusp tip was measured perpendicular to the
occlusal plane. The sector was determined using the
Ericson and Kurol classification.22 If only the analog
panoramic radiograph was available, a manual measure-
ment on tracing foil was performed. The duration of
traction was also taken into account. Time was
measured from the date of surgery until the bracket on
the canine could be connected with an archwire.
No statistical difference was found between the 2
study groups for the baseline parameters (see Table III).
The angulation of the included canines and distance
from the canine tip to the occlusal plane did not differ
significantly between the 2 groups before treatment. The
chi-square test did not show a difference between the
sector of the impacted canines (P 5 0.19). Therefore,
the severity of impaction in both groups is considered
the same. The duration of active traction on the canine
was not significantly different between the 2 groups
(P 5 0.12). Furthermore, the duration of the overall
orthodontic treatment did not differ significantly between
the 2 study groups (P 5 0.08). The choice of a closed vs
open approach was based on the preference of the ortho-
dontist and not on criteria such as the initial position of the
canine.
All patients were examined by the same calibrated
researcher (J.L.), who was trained to use the MCAI system
by a reference training data set. Grisar et al21 showed a
good intraclass correlation for the MCAI.21 Orthodon-
tists and prosthodontists had an intraclass correlation
coefficient of 0.80 and 0.89, respectively. Laypeople
scored 0.67 on the intrarater agreement. The 12 vari-
ables of the MCAI were scored during the clinical investi-
gation according to the scoring system found in Table I.
For all clinical parameters, the contralateral canine was
used as a reference.
Periodontal variables were collected during the clin-
ical investigation. Pocket probing depth was measured
by conventional methods using the Merritt B Probe
(Hu-Friedy, Chicago, Ill). The sulcus bleeding index by
M€ uhlemann and Son23 was used to determine the
amount of inflammation in the free gingiva. Bleeding
on probing was used to detect underlying inflammation
in the pockets.
Percussion sensitivity was tested by gentle tapping
on the cusp tip with the handle of a dental mouth mirror.
October 2020  Vol 158  Issue 4
Luyten et al
P value Treatment duration (d) P value
888
9.86 6 3.43 0.12 1128 0.08
It is well accepted that tooth ankylosis gives a metallic
sound and that a painful percussion is associated with
periapical pathology.24,25 A sensitivity test was con-
ducted to investigate the state of the pulp after the pro-
cedure and long orthodontic treatment. In this study, a
cold test was performed with Endo Ice (1,1,1,2-
tetrafluoroethene) (Coltene, Altst€atten, Switzerland).
According to Jespersen et al,26 Endo Ice is clinically
effective and accurate for pulpal diagnosis. This test
allows us to make a distinction between a positive vital
response, nonresponsive elements, elements with a
delayed response, or with a faster response than normal
to the cold test.27 Nonresponsive elements were consid-
ered to have heavy pulp chamber obliteration or to be
necrotic; delayed responses can be associated with
obliteration, a faster than normal response was seen
as a sign of possible pulpitis. In addition to the sensi-
tivity test, the color of the tooth was determined.
The patient's subjective judgment on the aesthetic
outcome, their estimation of treatment time, and their
evaluation of function was evaluated using a question-
naire. On the day of the clinical examination, all patients
were asked to complete a questionnaire about their
impacted teeth. The following questions were asked:
how they felt about the aesthetic appearance of their
treated canine, the treatment time, and whether they
suffered from discomfort during function (chewing).
Answers were registered using a visual analogue scale
(0 5 not being pleased; 10 5 very pleased).
This study was approved by the ethics board of the
University Hospitals Leuven (ref MP003112). The Com-
mittee confirms that it works in accordance with the In-
ternational Conference on Harmonisation Guidelines on
Good Clinical Practice principles, with the most recent
version of the Helsinki Declaration, and with applicable
laws and regulations. All participants signed informed
consent.
Statistical analysis
To compare the results of the MCAI, the angulation
of the canines, and the distance to the occlusal plane,
we used an unpaired Welch t test. Levene's test was
used to check for normality. Other discrete parameters
were analyzed with a chi-square test and Fisher's exact
test. Statistical significance was set at 0.05. SPSS
American Journal of Orthodontics and Dentofacial Orthopedics
Luyten et al
Table IV. Detail of MCAI parameters
MCAI parameters P values
Mesial papilla 0.673
Distal papilla 0.001
Marginal gingiva 0.001
Recession .0.999
Marginal gingival thickness 0.023
Mesiodistal crown angulation 0.157
Curvature of the marginal gingiva 0.005
Soft tissue color and texture 0.042
Root convexity 0.03
Tooth morphology 0.030
Vertical tooth position \0.001
Buccolingual angulation of crown 0.311
software (Version 24.0, IBM, Armonk, NY) was used for
statistical analysis. Prestudy sample size calculation
was difficult because of the novelty of the MCAI. There-
fore, a post-hoc power analysis was performed. A power
of 94.3% was calculated, which is well above the gener-
ally accepted 80%. On the basis of this result, the sample
size was determined to be adequate.
RESULTS
A significant statistical difference was observed for
the MCAI between open and closed exposure techniques
(P \ 0.001). The closed technique scored, on average,
3.00 in the MCAI rating scale, which corresponds to an
excellent aesthetic result (see Table II). The canines
treated with an open technique scored 5.64, which cor-
responds to a good aesthetic result (see Table I).
Further analysis of the individual parameters of the
MCAI showed statistically significant differences for
several parameters, mainly for parameters describing
the gingival characteristics included in the MCAI. Param-
eters describing the previously impacted canine and pa-
rameters comparing the previously impacted canine with
the contralateral canine both contribute to explaining
the difference between the open and closed groups. Sig-
nificant differences between the open and closed groups
were found for the following parameters: distal papilla,
marginal gingiva, curvature of the gingiva, gingival
thickness, root convexity, morphology, and vertical po-
sition. Statistical significance for these variables is shown
in Table IV. The open technique resulted in thinner
gingiva surrounding the canine compared with the
closed technique. The distal papilla is better preserved
when the open technique is used. However, no differ-
ence in the recession between the 2 groups was seen.
The discrepancy of the curvature of the marginal gingiva
as compared with the contralateral canine was better for
the closed technique. On the level of the dental charac-
teristics, no difference between the buccolingual crown
American Journal of Orthodontics and Dentofacial Orthopedics
e33
Table V. Detail of the color examination in the sample
Technique
Color Open Closed Total
Normal 18 10 28
Minimal discrepancy 5 9 14
Major discrepancy 2 9 11
Total 25 28 53
angulation was found. The closed technique had a better
outcome for root convexity, tooth morphology, and ver-
tical position.
The chi-square test showed significant results for
our secondary and tertiary aims: the pulpal status
(P \ 0.001) and the color of the tooth (P 5 0.021).
Canines treated with the closed technique tend to have
a different color compared with the contralateral canine.
The proportion of teeth with minor and major discolor-
ation is greater in the closed technique sample (see
Table V). Canines treated with a closed technique tend
to react more often in a delayed manner to cold testing
(P \ 0.001). When treated with the open technique, the
odds of reacting in a positive vital manner is 2.8 compared
with the closed technique (see Table VI).
For all other variables such as pocket probing depth,
percussion, and gingival inflammation, no statistically
significant difference could be demonstrated.
There is no difference in the patient's appraisal of the
aesthetic outcome in the questionnaires. The average
patient's judgment values were 9.0 of 10.0 and 9.2 of
10.0 for open and closed techniques on the visual
analogue scale, respectively. The duration of the treat-
ment was evaluated at 7.0 of 10.0 for the open tech-
nique and 6.5 of 10.0 for the closed technique. No
statistical difference between the above values was
obtained.
DISCUSSION
Most of the previous studies compared 1 technique
(open or closed) with nontreated canines or with other
techniques. Comparative studies on open vs closed tech-
niques are less frequent.28 This study aimed to evaluate
the difference in aesthetic outcome between the 2 tech-
niques in an objective manner using a standardized
scoring system (ie, MCAI). Recent studies generally use
a follow-up period between 3 months and 1 year after
debonding.19,29 However, in our study, the follow-up
period was almost 5 years.
The main disadvantage of the current study design is
the retrospective approach. This approach does not
allow to control all variables of the treatment. However,
this being an exploratory study, our objective was
October 2020  Vol 158  Issue 4
e34
Table VI. Detail of the sensitivity test in the sample
Technique
Sensitivity Open Closed Total
Nonresponsive 5 5 10
Delayed response 4 18 22
Positive vital response 14 5 19
Accelerated response 2 0 2 contralateral. Laypeople and orthodontists were asked
Total 25 28 53
primarily set on testing the MCAI in clinical practice. It
would be of interest to organize prospective studies to
evaluate the clinical and scientific value of the MCAI
and to study the pulpal characteristics of palatally
impacted canines treated by the closed or open tech-
nique. The use of a standardized index is, as clarified
in the introduction, very useful for the usage in meta-
analysis or to compare results of different researchers
in a fast manner. Of course, the usage of a standardized
method also comes with disadvantages such as (1) being
harder to interpret for outsiders, (2) time to get used to
the system, (3) loss of specific information, or (4) diffi-
culty to add own parameters. However, we believe that
being able to pool and compare data on a large scale
and thereby improving the quality of research in the field
outweigh the disadvantages.
A lot of published evidence about impacted maxillary
canines is available concerning the periodontal outcome
determined by probing depth, bleeding on probing,
inflammation, and recession. Wisth et al30 found that
open exposure leads to a more important attachment
loss on the palatal side. In our study, periodontal pocket
probing depth as a parameter of attachment loss did not
differ significantly between the 2 techniques. In addi-
tion, no statistical difference was obtained for the other
periodontal parameters in our study. This finding is in
line with previous studies.28,29,31
Parkin et al19 investigated the difference between an
open and closed technique in terms of aesthetic
outcome.19 Two panels, 1 consisting of orthodontists
and the other of laypeople, were asked to identify in
photographs the canine that was operated on. Ortho-
dontists were able to identify the operated side
(60.7%) more frequently than laypeople (49.7%). Both
panels were unable to make a difference between open
and closed techniques. D'Amico et al29 used a similar
method to evaluate the aesthetic outcome as Parkin
et al19; however, they only focused on the closed surgical
exposure technique.29 Fifty-six percent of the patients
had a good aesthetic outcome according to the ortho-
dontist expert panel.
In our study, the MCAI revealed a better aesthetic
outcome for canines treated with the closed technique.
October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Luyten et al
On average, the closed technique scored excellent
results, whereas the open technique scored good on
average.
This finding differs from that of Parkin et al19; they
showed no difference between the 2 techniques. However,
Parkin et al19 did focus on the identification of the previ-
ously impacted canine and the visual difference with the
to judge which tooth they found more beautiful. This
method differs greatly from our standardized comparison
with the MCAI. The study by Parkin et al19 was a multi-
center study, whereas almost all patients were treated
by the same orthodontist in our study. The panels judged
the canines on the basis of photographs. One could argue
that photographs do not reflect the true situation in the
mouth. According to Jackson et al,32 even minimal devi-
ations in the photography angle disturbs the orthodon-
tist's ability to judge midline deviation and Angle
classification.32 In contrast, the photographs make it
easier to blind board members. The research of Parkin
et al19 is seen as qualitative but is hard to compare with
our approach.
The research conducted by Smailien_e et al18 did not
find any difference in aesthetics between the 2 tech-
niques. Color, tooth position in the arch, and crown
inclination were measured. However, these represent
only a small part of all factors that determine the total
aesthetic picture of the tooth. The main disadvantage
of this study is the nonstandardized manner of report-
ing.
Only a few studies have investigated the difference in
pulpal status between canines treated with open or
closed surgical techniques. According to Oginni et al,33
yellow discoloration was observed in 67.4% of teeth
with pulp canal obliteration.33 In the same study, a clear
association is also shown between the amount of pulp
canal obliteration and the negative reaction on sensi-
tivity testing.33
In our study, teeth did react more often in a vital
manner to the cold test in the open technique sample
as compared with the closed technique sample. In the
closed technique, significantly more delayed responses
were noted. Seventy-two percent of the teeth treated
with an open technique had the same color as the
contralateral side. The closed technique sample had
the same color in only 40% of the patients. On the basis
of the findings of Oginni et al,33 we can hypothesize that
the frequency of pulpal canal obliteration was higher in
the closed technique than in the open technique.
Although Ling et al34 showed that palatal impacted
canines that are surgically exposed and orthodontically
aligned showed signs of pulpal obliteration, they did
not observe a difference between the 2 techniques.34
Luyten et al
This is in contrast with our study, in which the occur-
rence of pulp canal obliteration was higher in the closed
technique. This disparity could be explained by the
longer follow-up time between the removal of the
brackets and the moment of investigation in our study.
Pulp chamber obliteration is a finding that most of the
time originates a certain time after the pressure on the
dentoalveolar ligament has ceased. If the follow-up
time is from several months to 1 year, as is the case in
most research, the time is too short to detect pulp oblit-
eration, explaining why our findings conflict with those
of Ling et al.34
From the present data, patients in both groups were
mostly very pleased with the aesthetic result. This result
is comparable to that of the study by D'Amico et al,29 in
which only 6.5% of patients found their result unsatisfy-
ing.29 Almost no patients complained of discomfort dur-
ing function and chewing. In addition, the subjective
evaluation of the treatment time was usually comparable
for the 2 groups, with most patients finding the treat-
ment time quite long.
CONCLUSIONS
1. The closed technique has a better outcome in terms
of aesthetics, according to the MCAI scoring system.
2. Teeth treated with a closed technique had a delayed
reaction on sensitivity testing and showed more
discoloration in comparison with the contralateral
canine, indicating a higher incidence of pulp canal
obliteration in the closed group.
3. Further research using the MCAI scoring system is
necessary to confirm our results.
4. Further research is needed to elaborate on the long-
term effects of the pulpal status of palatal impacted
canines.
REFERENCES
1. Thilander B, Myrberg N. The prevalence of malocclusion in Swed-
ish schoolchildren. Scand J Dent Res 1973;81:12-21.
2. Bishara SE. Impacted maxillary canines: a review. Am J Orthod
Dentofacial Orthop 1992;101:159-71.
3. Cooke J, Wang HL. Canine impactions: incidence and manage-
ment. Int J Periodontics Restorative Dent 2006;26:483-91.
4. Fournier A, Turcotte JY, Bernard C. Orthodontic considerations in
the treatment of maxillary impacted canines. Am J Orthod 1982;
81:236-9.
5. Peck S, Peck L, Kataja M. The palatally displaced canine as a dental
anomaly of genetic origin. Angle Orthod 1994;64:249-56.
6. Kokich VG, Mathews DP. Surgical and orthodontic management of
impacted teeth. Dent Clin North Am 1993;37:181-204.
7. Chapokas AR, Almas K, Schincaglia GP. The impacted maxillary
canine: a proposed classification for surgical exposure. Oral Surg
Oral Med Oral Pathol Oral Radiol 2012;113:222-8.
American Journal of Orthodontics and Dentofacial Orthopedics
e35
8. Bass TB. Observations on the misplaced upper canine tooth. Dent
Pract Dent Rec 1967;18:25-33.
9. Becker A. Etiology of maxillary canine impactions. Am J Orthod
1984;86:437-8.
10. Becker A. In defense of the guidance theory of palatal canine
displacement. Angle Orthod 1995;65:95-8.
11. Sajnani AK, King NM. The sequential hypothesis of impaction of
maxillary canine - a hypothesis based on clinical and radiographic
findings. J Craniomaxillofac Surg 2012;40:e375-85.
12. Bedoya MM, Park JH. A review of the diagnosis and management
of impacted maxillary canines. J Am Dent Assoc 2009;140:
1485-93.
13. Cassina C, Papageorgiou SN, Eliades T. Open versus closed surgical
exposure for permanent impacted canines: a systematic review and
meta-analyses. Eur J Orthod 2018;40:1-10.
14. Chaushu S, Becker A, Zeltser R, Branski S, Vasker N, Chaushu G.
Patients perception of recovery after exposure of impacted teeth:
a comparison of closed-versus open-eruption techniques. J Oral
Maxillofac Surg 2005;63:323-9.
15. Sampaziotis D, Tsolakis IA, Bitsanis E, Tsolakis AI. Open versus
closed surgical exposure of palatally impacted maxillary canines:
comparison of the different treatment outcomes- a systematic
review. Eur J Orthod 2018;40:11-22.
16. Bj€orksved M, Arnrup K, Lindsten R, Magnusson A, Sundell AL,
Gustafsson A, et al. Closed vs open surgical exposure of palatally
displaced canines: surgery time, postoperative complications,
and patients’ perceptions: a multicentre, randomized, controlled
trial. Eur J Orthod 2018;40:626-35.
17. Parkin N, Benson PE, Thind B, Shah A, Khalil I, Ghafoor S. Open
versus closed surgical exposure of canine teeth that are displaced
in the roof of the mouth. Cochrane Database Syst Rev 2017;(8):
CD006966.
18. Smailien_e D, Kavaliauskien_e A, Pacauskien_e I. Posttreatment status
of palatally impacted maxillary canines treated applying 2 different
surgical-orthodontic methods. Medicina Kaunas 2013;49:354-60.
19. Parkin NA, Freeman JV, Deery C, Benson PE. Esthetic judgments of
palatally displaced canines 3 months postdebond after surgical
exposure with either a closed or an open technique. Am J Orthod
Dentofacial Orthop 2015;147:173-81.
20. Tsichlaki A, O'Brien K, Johal A, Fleming PS. Orthodontic trial out-
comes: plentiful, inconsistent, and in need of uniformity? A
scoping review. Am J Orthod Dentofacial Orthop 2018;153:
797-807.
21. Grisar K, Claeys G, Raes M, Albdour EA, Willems G, Politis C, et al.
Development and validation of the Maxillary Canine Aesthetic
Index. Clin Exp Dent Res 2018;4:216-23.
22. Ericson S, Kurol J. Radiographic examination of ectopically erupt-
ing maxillary canines. Am J Orthod Dentofacial Orthop 1987;91:
483-92.
23. M€ uhlemann HR, Son S. Gingival sulcus bleeding—a leading symp-
tom in initial gingivitis. Helv Odontol Acta 1971;15:107-13.
24. Campbell KM, Casas MJ, Kenny DJ, Chau T. Diagnosis of ankylosis
in permanent incisors by expert ratings, Periotest and digital sound
wave analysis. Dent Traumatol 2005;21:206-12.
25. Pigg M, Nixdorf DR, Nguyen RH, Law AS, National Dental Practice-
Based Research Network Collaborative Group. Validity of preoper-
ative clinical findings to identify dental pulp status: a national
dental practice-based research network study. J Endod 2016;42:
935-42.
26. Jespersen JJ, Hellstein J, Williamson A, Johnson WT, Qian F. Eval-
uation of dental pulp sensibility tests in a clinical setting. J Endod
2014;40:351-4.
October 2020  Vol 158  Issue 4
e36
27. Alghaithy RA, Qualtrough AJ. Pulp sensibility and vitality tests for
diagnosing pulpal health in permanent teeth: a critical review. Int
Endod J 2017;50:135-42.
28. Smailiene D, Kavaliauskiene A, Pacauskiene I, Zasciurinskiene E,
Bjerklin K. Palatally impacted maxillary canines: choice of
surgical-orthodontic treatment method does not influence post-
treatment periodontal status. A controlled prospective study. Eur
J Orthod 2013;35:803-10.
29. D’Amico RM, Bjerklin K, Kurol J, Falahat B. Long-term results of
orthodontic treatment of impacted maxillary canines. Angle
Orthod 2003;73:231-8.
30. Wisth PJ, Norderval K, Bøoe OE. Comparison of two surgical
methods in combined surgical-orthodontic correction of impacted
maxillary canines. Acta Odontol Scand 1976;34:53-7.
October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Luyten et al
31. Parkin NA, Milner RS, Deery C, Tinsley D, Smith AM, Germain P,
et al. Periodontal health of palatally displaced canines treated
with open or closed surgical technique: a multicenter, randomized
controlled trial. Am J Orthod Dentofacial Orthop 2013;144:176-84.
32. Jackson TH, Phillips CD, Koroluk LJ, Kirk C. Diagnostic accuracy of
intraoral photographic orthodontic records. J Esthet Restor Dent
2019;31:64-71.
33. Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of ra-
diographs, clinical signs and symptoms associated with pulp canal
obliteration: an aid to treatment decision. Dent Traumatol 2009;
25:620-5.
34. Ling KK, Ho CT, Kravchuk O, Olive RJ. Comparison of surgical and
non-surgical methods of treating palatally impacted canines. I.
Periodontal and pulpal outcomes. Aust Orthod J 2007;23:1-7.