The surgical exposure and application of

direct traction of unerupted teeth

Fraser McDonald, B.D.S., F.D.S.R.C.S., and
Wei Luen Yap, B.D.S., F.D.S.R.C.S.
London, England

This article presents a retrospective study of patients treated for impacted maxillary canines by a
combined surgical and orthodontic approach. All patients were assessed radiographically by means
of a lateral skull radiograph and an orthopantograph. No posteroanterior radiographs were taken.
Facial or lingual position within the arch was not determined, the height and inclination of the canine
being deemed more important. At surgery, a facial flap was raised first in all cases. Only if access
and isolation were poor was a palatal flap raised. Bone was removed as necessary. One contention
of this article is that the amount of bone removed is not important. It is the manner in which the
soft tissues and, in particular, the periosteum are handled that ultimately affects the results of the
surgical treatment. An attachment was bonded onto the tooth and the wound closed. The tooth was
then actively extruded, a removable appliance being preferable because more vertical control of
anchorage is possible. (AMJ ORTHOD 89: 331-340, 1986.)

Key words: Impacted canines, orthopantographic reproducibility, surgical exposure

T h e maxillary canine is the most frequently
impacted tooth in the anterior part of the mouth. ~Over
a period of 12 months from June 1982 to May 1983,
4.3% of all referrals to the oral surgery and orthodontic
departments at Basingstoke District Hospital were for
the treatment of impacted upper canines. Many treat-
ment alternatives are available, 2,3 but the one with the
best long-term prognosis for the canine tooth appears
to be attachment of an orthodontic bracket. 4 When de-
ciding on which approach is best suited to the clinical
situation, other factors, such as damage to adjacent
structures and patient motivation, should be assessed.
It should, however, be remembered that prevention of
impacted canines provides the best long-term results.
Thus, interceptive methods should be undertaken on
selected cases by patient review in early development.
METHODS
Selection of patients and treatment considerations
In the first instance, the patients attended a com-
bined oral surgical and orthodontic clinic for assess-
ment. In this study 64 patients were involved, 20 with
bilateral impacted canines and 44 with unilateral im-
pacted canines.
The assessment consisted of:
1. Patient factors
a. Age and medical history
Fromthe Department of Oral Surgery and Orthodontics, Basingstoke District
Hospital, Basingstoke, Hants, England.
b. Motivation and cooperation of the patient and
parents
2. Dental factors
a. Oral hygiene
b. The dentition with regard to conservation re-
quirements and with particular attention to the
prognosis of the first molars
c. The overall orthodontic requirements
d. The state and resorption of the deciduous canine
The radiographic examination involved an ortho-
pantograph (OPG) which will now be discussed in
detail.
Radiographic assessment
The main criticism of the orthopantograph is that it
is difficult to reproduce and standardize, and produces
some distortion. The standard teaching according to
Mills 5 is to assess impacted canines with lateral skull
and posteroanterior (PA) radiographs. It is believed,
however, that the PA view provides no further infor-
mation than the OPG, the latter being taken now as a
general screen of dental tissues. To determine whether
the OPG is a valid form of assessment, a separate series
of patients with unilateral impacted canines was se-
lected. All of these patients were under treatment at the
time. Each case had an OPG and a lateral skull radio-
graph taken on the same day. This was to ensure that
the canine had not altered its position between radio-
graphs.
Patients who had no first permanent molars were
331

332 McDonaM and Yap
Fig. 1. Tracings of rotational and lateral skull radiographs used
to establish a correlation between the angle of the maxillary
canine to first molar.
Fig. 2. Before surgical exposure and bracketing. This is an
atypical case with absent lateral incisors but is used to dem-
onstrate the technique.
excluded as were patients who had radiographs taken
on two separate occasions.
Tracings were made (as in Fig. 1) of the first max-
illary molar and the impacted canine. The first molar
was used because it was clearly visible on both radio-
graphs. The long axis of each tooth was then determined
Am. J. Orthod.
April 1986
Fig. 3. The buccal mucoperiosteal flap raised exposing the al-
veolar bone.
Fig. 4. The gel etchant on the crown of the tooth.
Fig, 5. After cleaning and drying, a chalky white appearance is
seen on the enamel.
and included in the tracing. The long axis of the canine
tooth was drawn through the midpoint of the maximum
width of the crown and the apex of the tooth. The long
axis of the first molar was drawn through the midpoint
of the cervical constriction of the maximum width o f
the crown of the tooth. The apex of the palatal root
Volume 89 Surgical exposure and application of direct traction of unerupted teeth 333
Number 4

Table I. Angles measured between the long axes of unerupted upper canines and upper first molars
Orthopantographreadings (X) Cephalostat readings (Y)
Cases l st ] 2nd [ 3rd 4th ' Average lstl2ndl3rdlethlAverage
1 37 36.5 32 31 34 24 21 22 21 22
2 51 49 53 50 51 46 47.5 44 40 44.5
3 66 64.5 67 68 66.5 44.5 47 48 52 48
4 28 31 31 30 30 26 26 27 26 26.5
5 62 69.5 70,5 66.5 67 48.5 48 49.5 52 49.5
6 24 19 19 25 22 18 21.5 18 18 19
7 35 41 43 38 39 43.5 49.5 52 42 46.75
8 27.5 25 32 27.5 29 40 54 45 44 45.75
9 28 33 33 30 31 28 28 29 27 28
10 28 31 28 30 29 61 53.5 60 57 58
11 66.5 64 ' 67 68 68 44 47.5 48 52 48
12 24 19 19 25 22 18 21.5 18 18 19
13 28.5 27 23.5 27 26.5 17 22 19 18 19
14 30.5 28 29 31 29.5 30 27.5 31 31 30
15 15 13 12 15 14 19 17 18 19 18
16 21 20.5 17.5 23 20.5 29 33.5 28 30 30
17 42.5 40 43 40 41 38 37 39 36 37.5
18 23 25 27 22.5 24.5 30.5 27 25 31 28.5
19 48 45 49.5 47 47.5 32 30 27 31 30
20 19 17 18 17 t8 18 17.5 17 20 18
21 47 45 49 49 47.5 38 41 42 43 41
22 36 27 31 28 30,5 42 40 41 40 40.75
23 40.5 47 48 45 45 30 23.5 33 33 30
24 26 22 24 25.5 24 43 44 46 41.5 44
25 25.5 23 29 28 26 12 10.5 13 14.5 12.5
26 24.5 27 26.5 29 27 25.5 27 29.5 26 27
27 39.5 37 36.5 41 38 30 28 27 26 27.5
28 41 45 42.5 40 42 43.5 47 46 47 46
29 82 79 83.5 89 83 68 65 61 58 63
30 49 45 47.5 43 46 56 50 57 55 54.5
31 34.5 30 33 32 32.5 49.5 51 47 45 48
32 32 35 37 32.5 34 14.5 17 20 21 18
33 34 37 35.5 32.5 35 30.5 27 33 29 30
34 49.5 47 46.5 45 49 27.5 29 30.5 26 28
35 13 10 15 17 14 23.5 27 24 27 25
36 41.5 43 45.5 40 42.5 29 31,5 33 35 32
37 12.5 15 17 13 14 24 26 27.5 30 27
38 21 23 25 22.5 23 31 29 30 27.5 29.5
39 66 60 61.5 63 62.5 58.5 62 60.5 62 60.75
40 25 27 25 24.5 25.5 24.5 27 23 25 25

Columns 1 and 2, T statistic value = 0.9590958.

Columns 3 and 4, T statistic value = 1.017068.
Columns 5 and 6, T statistic value = 0.9537399.
Columns 7 and 8, T statistic value = 0.6181787.
n = 40.
Degrees of freedom = 39.

was also u s e d if v i s i b l e . T h e a n g l e b e t w e e n t h e t w o
axes w a s t h e n m e a s u r e d (x a n d y). T h i s w a s c a r r i e d
out by t w o o b s e r v e r s (blind) o n a total o f 4 0 p a t i e n t s .
There w a s a p e r i o d o f 2 w e e k s b e t w e e n t h e first a n d
second t r a c i n g s . T h e lateral s k u l l r a d i o g r a p h s w e r e
traced first a n d a p e r i o d o f 2 d a y s a l l o w e d b e f o r e t h e
0PGs w e r e t r a c e d . T h i s w a s to e n s u r e t h a t o p e r a t o r
error w a s r e d u c e d to a m i n i m u m .
A n a d d i t i o n a l 30 p a t i e n t s w i t h t w o O P G s t a k e n
w i t h i n 6 m o n t h s o f e a c h o t h e r a n d u n e r u p t e d or i m -
p a c t e d canines were selected. One operator then mea-
sured the angle between molar and canine on two sep-
arate occasions.
From the OPG, the inclination of the canine, the
relation of the crown to adjacent teeth, and the position
of the apex were noted. No attempt was made with
334 M c D o n a l d a n d Yap
Fig. 6. The metal or plastic bracket already ligatured.
Fig. 7. The bracket held in place while the bonding agent is
setting.
Fig. 8. The flap repositioned with 3.0 black silk.
parallax to determine the position of the crown facially
or palatally except by clinical palpation. The technique
is always initiated from the facial aspect, even if the
crown is palpable palatal to the upper incisors. As stated
previously, it is not the amount of bone removed that
is important but how the soft tissues are handled.
Am. J. Orthod.
April 1986
Fig. 9. Clinical appearance before construction of a removable
appliance,
Fig. 10. The normal appliance for the application of elastic trac-
tion incorporating a 1 rnm preformed Roach clasp.
Fig. 11. The same appliance seen from the side.
It was determined from the assessments that the
following treatment options were available.
1. No treatment. The deciduous canine may have good
root length and may be esthetically acceptable. A|-
ternatively, the deciduous canine may have exfoli-
ated earlier and the canine space closed sponta-
neously leaving a good premolar-to-incisor contact
point. The canine should, however, be observed to
Volume89
Number4
Fig. 12. The appliance as fitted in the mouth with 5/18-inch elastic
in position.
ensure that no resorption of adjacent teeth will occur.
In many ways it is probably better to remove the
canine to prevent resorption.
2. Extraction of the maxillary canine and space closure.
This may be a difficult orthodontic treatment de-
pending on the size of the residual space and the
inclination of adjacent teeth.
3. TranSplantation. This procedure is relatively quick
but has an uncertain long-term prognosis. 6
4. Prosthetic or restorative treatment
5. Surgical exposure followed by forced extrusion
orthodontically. Several methods are described in
the literature. 7'8 The technique used in this series
was exposure and attachment of a preligatured
bracket, a procedure described later in detail.
The last three treatment options may require the
provision of space within the arch because the decid-
uous canine is smaller than the permanent canine in all
dimensions. To provide space in which to move teeth,
further extractions may be considered together with the
overall orthodontic treatment plan.
A not infrequent extraction pattern was loss of upper
second maxillary molars and lower third molars.
SURGICAL TECHNIQUE
Because of the complexity of the extractions, the
procedure was usually performed under general anes-
thesia. Exposure and bonding is possible, however, un-
der local anesthesia.
i. Using an aspirating syringe, 1:200,000 epi-
nephrine and 2% lignocaine were infiltrated into facial
and palatal tissues.
2. The facial mucoperiosteal flap was raised along
the gingival margin (Figs. 2 and 3).
3. The deciduous canine, if present, was removed
with forceps.
Surgical exposure and application Of direct traction of unerupted teeth 335
Fig. 13. The preorthodontic appearance of a bilateral case.
Fig. 14. The posttreatment appearance of case in Fig. 13.
4. While an assistant retracted the facial flap, bone
was removed with 3 or 5 mm chisels from the alveolus,
care being taken not to damage adjacent teeth. Only a
sufficient portion of the tooth was exposed to allow for
isolation and bonding of the bracket.
5. A minimal palatal flap was raised and the follicle
removed from around the tooth. This was to ensure that
the tooth could be isolated because tags of follicle tend
to contaminate the etchant and thereby nullify its effect.
6. The tooth was irrigated with sterile water and
dried with the aspirator.
7. This technique uses 50% phosphoric acid as the
etchant and an acrylic bonding agent. Figs. 4 and 5
show the etching process and the chalky white appear-
ance produced.
8. A preligatured edgewise bracket (Fig. 6) was
then bonded onto the tooth surface (Fig. 7).
9. The mucoperiosteal flap was repositioned with
3.0 black silk. The wire protruding through the mucosa
was cut to a suitable length and fashioned into a hook
(Fig. 8.).
It was thought advisable to give the patient a course
336 M c D o n a l d a n d Yap Am. J. Orthod
April 1986

Table II. Angulation of canine to first molar on

OPG taken to assess reproducibility of OPG

I1 2 I I 4
1 24 27 26 24
2 30 28 27 25
3 26 25 24 24
4 30 34 37 35
5 65 62 63 63
6 24 20 27 25
7 28 27 27 27
8 26 25 28 26
9 40 39 34 35
10 42 41 36 37
11 47 45 49 47
12 16 17 15 16
13 23 21 31 28
14 48 45 43 45
15 45 45 48 43
16 16 15 17 17
17 53 51 50 50
18 17 19 20 21
19 16 15 22 21
20 56 55 50 53
21 17 17 22 20
22 28 27 34 29
23 29 28 27 26
24 32 30 26 28
25 26 24 22 24
Fig. 15. The radiographs of case in Fig. 13. 26 23 23 24 24
27 9 10 14 12
28 0 0 3 2
of antibiotics postoperatively for 5 days (penicillin or 29 46 42 51 50
erythromycin). 30 40 44 50 46
Sutures Were removed 1 week later at which time 31 33 37 25 29
an appointment was made for orthodontic follow-up 4
Analysis of variance: Variance component--patients = 94.35%;
to 6 weeks later (Fig. 9).
method = 5.65%.
Columns 1 and 2, T statistic value = 1.425271.
ORTHODONTIC TECHNIQUE Columns 3 and 4, T statistic value = 1.668212.
1. The removabl e appliance was designed as shown T distribution of columns 1 and 2 = 0.8979227.
in Figs, 10 and 11. This applied traction along a desired T distribution of columns 3 and 4 = 0.8388555.

path of eruption using %6-inch heavy pull elastics

changed daily (Fig. 12). The patients were seen at four
weekly intervals and the appliance adjusted as nec-
essary.
2, Three canines needed soft tissue removed to ex-
pose the crown and reposition the bracket.
3. A short course of fixed appliances was carried
out to obtain alignment or to correct other aspects of
the malocclusion.
The patients were then observed 3 to 5 years after
the completion of treatment.
The clinical and radiologic assessments were carried
o u t b y one operator at Basingstoke District Hospital at
an average of 4 years and 1 month postoperatively. The
clinical assessment consisted of:
1. Plaque control and gingival health. This was as-
sessed by means of the indices of L6e and Silness.9,1o
2. The length of clinical crown was also measured in
the long axis of the tooth by means of a pair of
dividers and a stainless steel rule.
. Pocket depth was measured with a blunt, graduated
periodontal probe; the amelocemental junction was
determined by a sharp probe.
4. The state of the pulpal tissues was also assessed by
an electric pulp tester.
5. The width of keratinized mucosa was measured to
see if the approach from the buccal surface had
resulted in reduction of soft tissue. The measurement
consisted of two readings--on e maximal reading
from the height of the interdental papilla to the junc-
tion with the alveolar mucosa and one minimal mea-
surement from the middle of the clinical crown to
alveolar mucosa.
The radiologic assessment involved periapical ra
Volume89 Surgical exposure and application of direct traction of unerupted teeth 337
Number 4
diographs of canines and, where possible, of the canine
on the opposite side if untreated.
The untreated canines in the unilateral impactions
were used as the control sample. It was possible to
recall a total of 29 at review (five patients failed to
attend after repeated letters and ten had left the area
and found it too difficult to attend).
RESULTS
Student t test for the level of significance was ap-
plied to the groups of radiographic readings. The null
hypothesis tested was that no difference existed between
the two groups of readings. It was rejected if the level
of sigriificance was less than 0.05.
Comparing 40 OPGs to 40 lateral skull radiographs
showed no significant difference with r = 0.67.
Comparing two operators, tracing from 40 OPGs
and 40 lateral skull radiographs, showed no difference
using Student t test and r = 0.98 on both occasions.
A nested analysis of variance showed a greater vari-
ability of patients (94.35%) than did method (5.65%)
for the OPG readings.
Consequent to these results, the authors believe that
PA radiographs can provide no more information for
the assessment of impacted canines than that already
provided by panoramic radiographs.
Of the original group of patients referred for the
treatment of impacted canines (4.3% of all referrals for
a 12-month period), 44 canines were exposed, 14 re-
moved, 6 transplanted, and 2 of the patients kept under
observation. The main reasons for not exposing the
canines were patients unsuitability because of age or
unwillingness to undergo orthodontic treatment. None
of the patients was recalled for review because treatment
was still being undertaken.
The series recalled for review consisted of 64 pa-
tients, l l ) o f whom had associated missing maxillary
lateral incisors or peg-shaped laterals. There were 16
men and 48 women. Four patients were treated under
local anesthesia, the remainder under endotracheal in-
tubation for associated extractions.
Forty-five patients returned for review--29 with
unilateral impactions, 16 with bilateral impactions.
There were 33 women and 12 men. Approaching from
the facial aspect produced no problems in terms of
access; five canines required a larger palatal flap raised
to aid the bonding procedure. In general terms, the
palatal flap was raised to ensure that the crown of the
canine could be totally isolated for the purpose of etch-
ing, thus preventing contamination of the etchant.
The extent of bone removal was not considered
important. The damage to the soft-tissue flap was
deemed of utmost importance--in particular, the peri-
osteum, which was handled with all possible care.
There were no postoperative complications. The
bracket did not become dislodged even during active
treatment. During treatment the following problems
were encountered.
1. Five canines required re-exposure--that is, the
excision of overlying mucosa but no removal of bone.
This was indicated when the bracket was partially vis-
ible, but inadequate to contemplate full-arch fixed me-
chanics and ligation to the arch wire.
2. Six canines required rebracketing following
eruption.
3. Five patients were transferred to other ortho-
dontic practitioners.
4. Three patients failed to attend orthodontic fol-
low-up. After continued efforts to contact these indi-
viduals, it was learned that two of the canines had
erupted spOntaneously and the brackets had been re-
moved by the practitioners concerned. The third patient
has to date not replied to extensive correspondence.
5. An additional three patients did not respond to
treatment. It was believed that the major cause of failure
was lack of patient cooperation; however, one case was
Started with a fixed appliance that resulted in intrusion
of the incisors. Although a clinical diagnosis of early
ankylosis was made, no radiographic change was found.
After consultation with patients and parents, these teeth
were repositioned surgically. This does not provide a
good prognosis, although all teeth were found to be
situated in a more favorable position following ex-
posure.
Forty-nine percent of all active treatment time was
carried out with the removable appliance system; 13
patients were treated solely with removable appliances.
The assessment of the periodontal status showed the
following:
1. The plaque index from facial, palatal, and in-
terdental areas (scoring 0 to 3) showed 14 control ca-
nines scoring 1, and 14 operated canines scoring 1.
There were no scores greater than 1, all other canines
scoring 0.
2. Pocket depths varied from 1.5 to 2 mm buccal,
palatal, mesial, and distal.
Two cases showed signs of recession--one showed
2 mm of cementum above the gingival margin, the other
0.5 mm.
Because of the technical inability to take long cone
periapical radiographs, only a few criteria were ex-
amined. The lamina dura appeared normal; the apices
were closed and no signs of abnormal radiolucency or
radiopacity were visible.
It was believed necessary to establish the fact that
the widths of keratinized mucosa and clinical crown
height were comparable for control and operated teeth.
Treatment times varied from 5 to 44 months with
338 McDonald and Yap Am. J. Orthod.
April 1986

Table III. Periodontal status of teeth

Attached gingival width

Clinical crown height Control Treated side

Control I Treated side Minimum* } Maximum* Minimum* ] Maximum*

10 10 5 8 6 8
12 12 6 8 5 9
9 13 5 9 4 7
8 11 4 7 4 6,5
9 15 4 6 5 7
10 16 4 6.5 5 9
10 10 5 7 5 7
9 11 5.5 7 6 9
9 9 4 6 4 6.5
7 8 5 7 6 9
10 12 5 8 5 8.5
8 10 6 9 4 7
11 11 5 8.5 5 7
11 14 4 7 5 7
11 12 5 7 6 9
10 15 6 9 4 6
9 13 5 8 5 9
12 10 5 9 6 11
12 9 5 9 5 8
15 8 6 10 4 7
14 8 4 7 5 9
13 9 3 5 3 7
10 10 3 6 4 8
11 11 4 7 5 9
10 11 5 8 4 7
9 10 5 7 5 9
10 11 6 9 4 7
10 12 4 7 5 8

*Minimum = minimal attached gingival width in millimeters; maximum = maximal attached gingival width in millimeters.
T statistic (clinical crown height) = - 0.9951139.
Level of significance (theta) = 0.8993149.
Attached gingival width:
Minimal T statistic value = 0,483147.
Level of significance = 0.9757201,
Maximal T statistic value = - 1.066687.
Level of significance = 0.9953686.

a mean of 19 months, although this dealt with all aspects
of the malocclusion.
Treatment of canines solely with removable appli-
ances varied from 5 to 11 months. However, on average
a total of 3 months was spent correcting the facial/
palatal position of the teeth.
DISCUSSION
All attempts to expose and align unerupted canines
that have been described involved lengthy and expen-
sive treatment. Careful patient selection and preparation
therefore are essential as is cooperation between the
orthodontist and the oral surgeon. The latter should
ensure that no subsequent treatment be required except
for routine dental care.
A case is illustrated of bilateral impacted canines
(Figs. 13 and 14). The final radiographs show an oc-
clusion with only the upper right third molar to erupt
(Fig. 15).
When observing the response of the incisor teeth,
the removable appliances seemed to offer more in ver-
tical anchorage than did the fixed appliances.
The long-term status of the teeth appears better than
that following autotransplantation ~2 or removal of mu-
cosa and packing the defect.~4
Procedures that involved removal of soft tissue, no
Volume 89 Surgical exposure and application of direct traction of unerupted teeth 339
Number 4

Table III. - - C o n t ' d .

Attached gingival width

Clinical crown height Control Treated side

Control ] Treated side Minimum* I Maximum* Minimum* Maximum*

10.5 10 5 9 5 9
12 11 4 7 6 9
9 4 7
9 5 9
8 3 6.5
10 4 7
10 4 7.5
12 5 8
12 4.5 7
15 3.5 6
10 4 7
11 5 8
10 5 8
11 4 7
9 5 9
8 4 7
10 6 9
11 3.5 7
12 4 8
12 4.5 9
11 5 9
9 4 7
10 5 8
11 6 9
11 4.5 7
9 4 7.5
9 5 9
8 4.5 8

matter what the means o f attachment, s h o w e d signifi- REFERENCES

cant peridontal p r o b l e m s . " O n l y two o f the cases in
this series s h o w e d loss of attachment, one being less
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Other studies using ligation techniques s h o w e d fur-
ther p r o b l e m s o f external resorption or ankylosis. 13
CONCLUSIONS
l. T h e impacted maxillary canine is a c o m m o n
problem o f w h i c h all dental practitioners should be
aware.
2. The technique described is relatively simple and
uses materials available in m o s t specialist practices or
joint clinics.
3. It does not appear necessary to assess the facial
or palatal position o f the canine.
4. Radiographic assessment needs only the rotary
screen or O P G and the lateral skull radiograph.
5. Regardless o f which technique is used, the soft
tissues must be handled with great care.
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5. Mills JRE: Principles and practice of orthodontics. London,
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April 1986

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