SYSTEMATIC REVIEW

Periodontal status after surgical-orthodontic

treatment of labially impacted canines with
different surgical techniques: A systematic review
Serena Incerti-Parenti,a Vittorio Checchi,b Daniela Rita Ippolito,c Antonio Gracco,d and Giulio Alessandri-Bonettie
Bologna, Trieste, Brescia, and Padua, Italy

Introduction: Good periodontal status is essential for a successful treatment outcome of impacted maxillary ca-
nines. Whereas the surgical technique used for tooth uncovering has been shown not to affect the final peri-
odontal status of palatally impacted canines, its effect on labially impacted canines is still unclear. Methods:
Searches of electronic databases through January 2015 and reference lists of relevant publications were
used to identify studies evaluating the periodontal status of labially impacted canines after combined surgical-
orthodontic treatment. Two reviewers independently screened the articles, extracted data, and ascertained
the quality of the studies. Results: Ninety-one studies were identified; 3 were included in the review. No included
study examined the periodontal outcome of the closed eruption technique. Excisional uncovering was reported
to have a detrimental effect on the periodontium (bleeding of the gingival margin, 29% vs 7% in the control group;
gingival recession,
0.5 mm [SD, 1.0] vs
1.5 mm [SD, 0.8] in the control group; and width of keratinized gingiva,
2.6 mm [SD, 1.4] vs 4.1 mm [SD, 1.5] in the control group). Impacted canines uncovered with an apically posi-
tioned flap had periodontal outcomes comparable with those of untreated teeth. Conclusions: The current liter-
ature is insufficient to determine which surgical procedure is better for periodontal health for uncovering labially
impacted canines. (Am J Orthod Dentofacial Orthop 2016;149:463-72)

M
axillary canine impaction is a clinical condition
commonly encountered in dentistry. Approxi-
mately 2% of the general population and 4%
of the subjects referred to orthodontists are affected,1,2
with a third of the impacted maxillary canines located
labially.3
Arch length deficiency has been reported to play an
important role in the etiology of labial impactions:
Jacoby4 found that only 17% of labially impacted ca-
nines had sufficient space to erupt. Orthodontic
a
PhD student, Unit of Orthodontics, Department of Biomedical and Neuromotor
Sciences, University of Bologna, Bologna, Italy.
b
Researcher, Department of Medical Sciences, University of Trieste, Trieste, Italy.
c
Postgraduate student, Department of Orthodontics, School of Dentistry, Univer-
sity of Brescia, Brescia, Italy.
d
Assistant professor, Department of Neuroscience, University of Padua, Padua,
Italy.
e
Associate professor, Unit of Orthodontics, Department of Biomedical and Neu-
romotor Sciences, University of Bologna, Bologna, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Giulio Alessandri-Bonetti, Unit of Orthodontics,
Department of Biomedical and Neuromotor Sciences, University of Bologna,
Via San Vitale 59, Bologna 40125, Italy; e-mail, giulio.alessandri@unibo.it.
Submitted, February 2015; revised and accepted, October 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.10.019
mechanics to open the space for the canine crown might
lead to spontaneous eruption, but when space has been
created and the canine does not erupt within a reason-
able time, surgical uncovering of the impacted tooth
should be considered. Three techniques are generally
used to uncover labially impacted canines: excisional
uncovering (gingivectomy), apically positioned flap,
and closed eruption.5
One fundamental indicator of a successful outcome
in the treatment of impacted canines is the final peri-
odontal status.6 A recent randomized clinical trial by
Parkin et al7 showed that exposure and alignment of
palatally impacted maxillary canines has a small peri-
odontal impact that is unlikely to be clinically relevant,
without significant differences in periodontal health be-
tween the open and closed techniques. Labial impac-
tions seem to be more challenging to manage without
adverse periodontal problems, and the surgical tech-
nique used to uncover the canine is thought to be critical
for the final periodontal health because it affects the
amount of attached gingiva over the tooth crown after
eruption.8 However, the actual periodontal impact of
the surgical technique used to uncover labially impacted
canines is still unclear; to date, no systematic review has
been undertaken on this topic.
463
464
The purpose of this study was to systematically re-
view the literature on the periodontal status of labially
impacted canines after combined surgical-orthodontic
treatment with different surgical approaches to clarify
whether there is sufficient evidence to support one sur-
gical technique over the others in terms of periodontal
health.
MATERIAL AND METHODS
Eligibility was assessed on the basis of the following
inclusion criteria.
 The population was patients receiving surgical treat-
ment to correct labially impacted maxillary canines.
No restriction for age, malocclusion, or type of ortho-
dontic treatment was applied. Studies including both
labial and palatal impactions were excluded because
of the anatomic differences in the keratinized tissues
between the palatal and labial mucosae. Studies
including both incisors and canines were excluded
because of the differences in the etiology of their im-
pactions.
 The intervention was combined surgical-orthodontic
treatment of labially impacted canines. At least 1 of
the following surgical techniques had to be used in
the study: closed surgical technique, excisional un-
covering (radical exposure), or apically positioned
flap.
 For comparison, when 1 technique was considered,
the untreated contralateral side had to be used as
the control. When 2 surgical techniques were
compared, no untreated control group was required.
 Outcomes; studies were considered for inclusion if at
least 1 of the following parameters was evaluated.
1. Plaque accumulation: plaque volume on the
dental surfaces. The Plaque Index by Silness
and Loe,9 scored with a 4-point scale (0-3), is
widely used to assess plaque accumulation.
2. Gingival inflammation: assessment of the in-
flammatory conditions of the gingiva can be
based on visual inspection and bleeding of the
gingival margin (Gingival Index)10 or on gingival
bleeding tendency alone (Gingival Bleeding In-
dex)11 or bleeding tendency.12
3. Recession: distance from the cementoenamel
junction (CEJ) to the gingival margin, with the
gingival margin apical to the CEJ being positive,
and the gingival margin coronal to the CEJ being
negative.
4. Periodontal probing depth: distance from the
gingival margin to the location of the tip of a
periodontal probe inserted into the pocket.
April 2016  Vol 149  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Incerti-Parenti et al
5. Clinical attachment level: distance from the CEJ
to the location of the inserted probe tip.
6. Width of the keratinized gingiva: distance be-
tween the most apical point of the gingival
margin and the mucogingival junction.
7. Width of the attached gingiva: distance between
the mucogingival junction and the projection on
the external surface of the bottom of the gingival
sulcus. It is obtained by subtracting the peri-
odontal probing depth from the width of the ker-
atinized gingiva.
8. Crestal bone loss: distance between the CEJ and
the alveolar bone crest measured on intraoral ra-
diographs.
 Study designs: randomized controlled trials,
controlled clinical trials, and observational studies
(cohort and case-control studies) were considered for
inclusion if they fulfilled the population, intervention,
comparisons, and outcomes criteria detailed above.
Information sources, search strategy, and study
selection
The following databases were searched from their
inception to January 2015 for relevant studies: PubMed,
Cochrane Central Register of Controlled Trials, LILACS,
and Scopus. There were no language restrictions. To iden-
tify the relevant studies the following search strategy was
used: Search ((impact* OR unerupt* OR ectopic*) AND
(labial* OR buccal* OR vestibular*) AND ((maxilla* OR up-
per) AND (canine* OR cuspid*)) AND (surgery or surgi-
cal*)); filters: humans. Further studies were identified by
hand searching the reference lists of all relevant articles.
The first step in the screening process was to “undu-
plicate” the references by importing them into the refer-
ence management software “Mendeley” (http://www.
mendeley.com/features/reference-manager/). Two au-
thors (D.R.I., S.I-P.) independently screened titles and
abstracts. For studies that appeared to be relevant, or
when a definite decision could not be made based on
the title or abstract alone, the full article was obtained
and independently examined by the reviewers for
detailed assessment against the inclusion criteria.
Because of the dichotomous nature of the ratings
(accept or reject), agreement between the assessors (in-
terassessor reliability) was formally assessed using the
kappa statistic. Disagreements were resolved by discus-
sion. When resolution was not possible, a third reviewer
(G.A-B.) was consulted.
Data items and collection
Data extraction included the following items: (1) first
author, year of publication, and location; (2) study
Incerti-Parenti et al
design; (3) population characteristics (subjects enrolled,
mean age, and sex distribution); (4) intervention (surgi-
cal exposure, orthodontic traction); (5) investigated
comparisons; (6) follow-up of the study; (7) outcome
measures; (8) significance level of the statistical tests;
and (9) outcomes.
Two authors (D.R.I., S.I-P.) independently performed
the data extraction using a previously piloted form. Dis-
agreements were resolved by discussion. When resolu-
tion was not possible, a third reviewer (G.A-B.) was
consulted.
Quality assessment in the studies
Two authors (V.C., A.G.) were blinded to the authors
and the sources of each reference and independently as-
sessed the research design as well as a 3-category rating
of the internal validity of each study (according to
criteria that varied depending on the study design), as
stated by the U.S. Preventive Services Task Force
(Table I).13 Disagreements were resolved through
consensus. The Spearman rank correlation coefficient
was applied to evaluate the agreement between the
raters.
Data synthesis
The findings of the studies included in the systematic
review were gathered. A quantitative synthesis using
formal statistical techniques such as meta-analysis
seemed inappropriate because the selected studies
were too few, with nonrandomized designs and a lack
of homogeneity in the study settings. Therefore, a narra-
tive synthesis was carried out.
RESULTS
Study selection and characteristics
The Figure shows the flow of the literature search ac-
cording to the PRISMA format.14 The comprehensive
search yielded 91 potentially relevant studies. Screening
excluded 77 publications based on titles and abstracts.
The full-text analysis of the remaining 14 studies led
to the exclusion of 11 more articles (Table II).6,15-24
Therefore, 3 studies fully met the eligibility criteria and
were included in the review (Tables III and IV ).25-27
Excellent agreement between reviewers was found
both in the screening (titles and abstracts, k 5 0.917;
full texts, k 5 1.000) and in the quality assessment
(Table V; P 5 1.000).
Results of individual studies
The authors of 1 prospective study evaluated the ef-
fects on the periodontal tissues of 2 surgical approaches:
American Journal of Orthodontics and Dentofacial Orthopedics
465
Table I. US Preventive Services Task Force rating of
study quality
Definition of ratings
Study design
I Properly randomized controlled trial
II-1 Well-designed controlled trial without randomization
II-2 Well-designed cohort or case-control analytic study,
preferably from more than 1 center or research
group
II-3 Multiple time series with or without the intervention;
dramatic results in uncontrolled experiments could
also be regarded as this type of evidence
III Opinions of respected authorities, based on clinical
experience, descriptive studies, and case reports, or
reports of expert committees
Internal validity*
Good The study meets all criteria for that study designy
Fair The study does not meet all criteria for that study
design but is judged to have no fatal flaw that
invalidates its resultsy
Poor The study contains a fatal flaw
Derived from Harris et al.13
*Internal validity is the degree to which the study provides valid ev-
idence for the population and setting in which it was conducted;
y
criteria for grading internal validity (limited to the study designs
of the studies included in the review) were reported in Table V.
radical exposure (entire labial aspect of the crown
exposed) and partial exposure (2-3 mm of keratinized
tissue maintained with either an apically positioned
flap or a tissue excision).25 Twenty-four patients with
a unilateral labially impacted maxillary canine treated
with surgical exposure and orthodontic alignment
were enrolled; 12 had radical exposure, and 12 had par-
tial exposure. Periodontal status (including plaque accu-
mulation, gingival inflammation, gingival recession, loss
of attachment, and width of attached gingiva) was eval-
uated 6 to 24 months after removal of the fixed appli-
ances. The radical exposure group appeared to have
more gingival inflammation, gingival recession, and
loss of attachment than both the contralateral untreated
canine and partial exposure groups. However, only the
values of the width of the attached gingiva were reported
in the article; the other data were provided solely as box-
and-whisker plots (without medians indicated)
(Table IV). Therefore, it was not possible to accurately
present in the review the extent of the detrimental effect
of radical exposure when compared with untreated
canines.
Kim et al27 evaluated the periodontal health of 23
labially displaced canines, exposed with an apically posi-
tioned flap technique. Periodontal outcomes, evaluated
at least 1 year after the surgery, were compared with
those of the contralateral untreated canines. Canines
exposed with an apically positioned flap, when
April 2016  Vol 149  Issue 4
466
Fig. Flow diagram (in PRISMA format) of the literature search.
Table II. Excluded studies with reasons
Authors, year Reason for exclusion
Caminiti et al,15 1998 Unsuitable sample (palatal and labial
impactions)
Crescini et al,16 1994 Unsuitable sample (palatal and labial
impactions)
Crescini et al,6 2007 Unsuitable sample (palatal and labial
impactions)
Gaulis and Joho,17 1978 Unsuitable sample (palatal and labial
impactions), inadequate
methodology (no inferential
statistics)
Odenrick and Mod
eer,18 Unsuitable sample (incisors and
1978 canines, palatal and labial
impactions), inadequate
methodology (no inferential
statistics)
O'Dowling,19 2009 Review outcomes of interest not
reported in the study
Quirynen et al,20 2000 Unsuitable sample (palatal and labial
impactions)
Soroka-Letkiewicz et al,21 Unsuitable sample (incisors and
2005 canines), inadequate methodology
(no inferential statistics)
Szarmach et al,22 2006 Unsuitable sample (palatal and labial
impactions)
Vermette et al,23 1995 Unsuitable sample (incisors and
canines)
Wisth et al,24 1976 Unsuitable sample (palatal and labial
impactions)
April 2016  Vol 149  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Incerti-Parenti et al
compared with untreated canines, showed no signifi-
cantly different values in the Plaque Index, Gingival In-
dex, probing depth, width of attached gingiva, clinical
crown length, and crestal bone loss (Table IV).
Only 1 study directly compared excisional uncovering
and the apically positioned flap technique.26 Twenty-
one participants received a radical exposure, and 29 pa-
tients had an apically positioned flap. The untreated
contralateral canines served as controls. The apically
positioned flap group, when compared with the control
group, showed no significant differences in Gingival
Bleeding Index, width of keratinized gingiva, peri-
odontal probing depth, and recession. Conversely,
most of the periodontal indexes after excisional uncov-
ering were less favorable than those in untreated canines
(Table IV).
DISCUSSION
Summary of evidence
Excisional uncovering of impacted canines was re-
ported to have a detrimental effect on the periodontium:
uncovered canines, when compared with the contralat-
eral untreated teeth, had significantly more gingival
inflammation (Gingival Bleeding Index, buccal: radical
exposure, 29%; control, 7%), gingival recession (radical
exposure: mean,
0.5; SD, 1.0 mm; and control: mean,
Incerti-Parenti et al 467

Table III. Characteristics of included studies

Characteristics Boyd,25 1984 Tegsj€o et al,26 1984 Kim et al,27 2007
Participants
Inclusion criteria Unilateral labially impacted Unilateral labially impacted Labially impacted maxillary canine
maxillary canine maxillary canine
Surgical exposure and orthodontic Surgical exposure of the impacted Surgical exposure of the impacted
alignment of the impacted canine performed between canine through APF
canine 1977 and 1979
All appliances removed for a Minimum recall period of 1 year
minimum of 6 months after the surgery
Subjects, n (% male) 24 (33%) 50 (44%) 20 (-)
Mean age (y) (SD, range) - (-, 15/22) at time of the study 12.9 (-, 10/18) at time of the -
surgery
Intervention RE: entire crown exposed by the RE: surgical uncovering; surgical Full fixed orthodontics; surgical
window approach dressing for 1 week; uncovering (APF); surgical
orthodontic traction dressing for 1 week;
orthodontic traction
PE: 2-3 mm of keratinized tissue APF: Surgical uncovering; surgical
maintained with either an APF dressing for 1 week;
or a tissue excision orthodontic traction
Comparisons RE vs CTR RE vs CTR APF vs CTR
PE vs CTR APF vs CTR
RE vs PE RE vs APF
Recall period (mo) 6-24 after removal of fixed 30-56 after surgical exposure Minimum of 12 after surgery
appliances
Outcomes PI, GI, BT, REC, PPD, LA, WAG GBI, WKT (lab), PPD, REC PI, GI, PPD, WAG, clinical crown
length, bone loss
Study design Controlled clinical trial Retrospective cohort study Retrospective cohort study
RE, Radical exposure; PE, partial exposure; APF, apically positioned flap; CTR, control group; PI, Plaque Index; GI, Gingival Index; GBI, Gingival
Bleeding Index; BT, bleeding tendency; REC, recession; PPD, pocket probing depth; LA, loss of attachment; WAG, width of attached gingiva; WKT,
width of keratinized gingiva; lab, labial.

1.5; SD, 0.8 mm), and reduced width of keratinized
gingiva (radical exposure: mean, 2.6; SD, 1.4 mm; and
control: mean, 4.1; SD, 1.5 mm).25,26
For the closed eruption vs the control groups, none of
the included studies compared the periodontal out-
comes between canines uncovered with the closed erup-
tion technique and untreated canines. The excluded
studies on this topic had inconsistent results. Crescini
et al,6,16 using a closed surgical technique with tunnel
traction, at a 3-year follow-up found no significant dif-
ferences between the periodontal indexes of treated and
untreated canines, with a significance level set at 0.05,
whereas Vermette et al23 detected in the closed eruption
group narrower attached gingiva on the distal surface
(closed surgical technique: mean, 3.5; SD, 1.49 mm;
and control: mean, 4.2; SD, 1.33 mm; P \0.03) and
crestal bone (probing bone level) located more apically
on the facial surface (closed surgical technique: mean,
2.1; SD, 0.79 mm; and control: mean, 1.6; SD,
0.51 mm; P \0.02). However, the findings from these
studies were not conclusive because they included
both palatal and labial impactions6,16 or both incisors
and canines.23 Moreover, Crescini et al included only
unilateral deep infraosseous impactions, thus restricting
the external validity of their study. The differences found
by Vermette et al were small (\1 mm) and therefore un-
likely to be clinically significant.
For the apically positioned flap vs the control groups,
the periodontal statuses of the canines were not signif-
icantly different.26,27 Boyd25 failed to differentiate exci-
sional uncovering from apically positioned flap (both
were included in the “partial exposure” group); there-
fore, no conclusion could be drawn regarding the peri-
odontal status after the apically positioned flap
approach compared with untreated canines. Among
the excluded studies, Vermette et al,23 who analyzed
the distance from the gingival margin to the CEJ (with
negative recording indicating a gingival margin located
apically to the CEJ), found that teeth uncovered with an
apically positioned flap showed more apical gingival
margins on the mesial aspect (apically positioned flap:
mean, 2.1 mm; SD, 0.67 mm; and control: mean,
2.4 mm; SD, 0.61 mm; P \0.01) and the facial surfaces
(apically positioned flap: mean, 0.6 mm; SD, 1.04 mm;
and control: mean, 1.3 mm; SD, 0.69 mm; P \0.01).
Moreover, they found greater crown length on the mid-
facial surface (apically positioned flap: mean, 10.1 mm;
SD, 1.00 mm; and control: mean, 9.5 mm; SD, 0.98 mm;

American Journal of Orthodontics and Dentofacial Orthopedics April 2016  Vol 149  Issue 4
April 2016  Vol 149  Issue 4

468
Table IV. Periodontal outcomes reported in the included studies
Boyd,25 1984 Tegsj€o et al,26 1984 Kim et al,27 2007

Significance Significance Significance

only only only
CTR RE PE P \0.05 CTR RE APF P \0.01 CTR* APF* P \0.05
PI 0.66 (SE, 0.143) 0.75 (SE, 0.150) NS
GI NR NR NR RE . CTR 0.30 (SE, 0.108) 0.43 (SE, 0.120) NS
RE . PE
BT NR NR NR RE . CTR
RE . PE
GBIb 7% 29% 7% RE . APF
RE . CTR
REC NR NR NR RE . CTR
1.5 mm
0.5 mm
0.9 mm RE . CTR
RE . PE (SD, 0.8 mm)y (SD, 1.0 mm) (SD, 1.2 mm)

1.1 mm
(SD, 0.9 mm)z
PPD
Buccal 1.6 mm 1.2 mm 1.4 mm APF . RE 1.76 mm 1.86 mm NS
(SD, 0.6 mm)y (SD, 0.4 mm) (SD, 0.4 mm) CTR . RE (SE, 0.092 mm) (SE, 0.105 mm)
American Journal of Orthodontics and Dentofacial Orthopedics

1.6 mm
(SD, 0.4 mm)z
Mesial 1.9 mm 2.4 mm 2.1 mm NS
(SD, 0.6 mm)y (SD, 0.6 mm) (SD, 0.5 mm)
2.2 mm
(SD, 0.7 mm)z
Palatal 1.9 mm 2.1 mm 2.0 mm NS
(SD, 0.5 mm)y (SD, 0.5 mm) (SD, 0.5 mm)
2.0 mm
(SD, 0.5 mm)z
Distal 2.0 mm 2.6 2.2 mm NS
(SD, 0.6 mm)y (SD, 0.6 mm) (SD, 0.6 mm)
2.1 mm
(SD, 0.6 mm)z
LA NR NR NR RE . CTR
RE . PE
WKG 4.1 mm 2.6 4.3 mm APF . RE
(SD, 1.5 mm)y (SD, 1.4 mm) (SD, 1.8 mm) CTR . RE

Incerti-Parenti et al
3.9 mm
(SD, 1.5 mm)z
WAG NR 0.0 mm 3.67 mm NR 3.73 mm 4.16 mm NS
(SD, 1.72 mm) (SE, 0.254 mm) (SE, 0.410 mm)
Clinical 9.01 mm 9.14 mm NS
crown (SE, 0.418 mm) (SE, 0.371 mm)
length
Incerti-Parenti et al 469

P \0.02), increased probing attachment level on the

CTR, control group; RE, radical exposure; PE, partial exposure; APF, apically positioned flap; PI, Plaque Index; GI, Gingival Index; BT, bleeding tendency; GBIb, Gingival Bleeding Index (buccal); REC,
Significance facial surface (apically positioned flap: mean,
P \0.05
only

1.4 mm; SD, 1.15 mm; and control: mean,

0.8 mm; SD, 0.62 mm; P \0.02), increased width of
NS
(SE, 0.185 mm)
attached gingiva on the facial surface (apically posi-
tioned flap: mean, 3.5 mm; SD, 2.08 mm; and control:
Kim et al,27 2007

1.36 mm

mean, 1.9 mm; SD, 0.68 mm; P \0.002), increased

APF*

Recession; PPD, pocket probing depth; LA, loss of attachment; WKT, width of keratinized gingiva; WAG, width of attached gingiva; NR, not reported; NS, not significant.
probing bone level on the mesial aspect (apically posi-
tioned flap: mean, 2.3 mm; SD, 0.57 mm; and control:
mean, 1.8 mm; SD, 0.71 mm; P \0.007), the facial
aspect (apically positioned flap: mean, 2.4 mm; SD,
(SE, 0.173 mm)

0.98 mm; and control: mean, 1.6 mm; SD, 0.61 mm;
1.08 mm

P \0.002), and the distal aspect (apically positioned

CTR*

flap: mean, 2.2 mm; SD, 0.62 mm; and control: mean,
1.7 mm; SD, 0.57 mm; P \0.007). As stated above,
the sample of Vermette et al consisted of both canines
Significance

and incisors, and the inadequate sample was the reason

P \0.01
only

for the exclusion of this study.

None of the included studies examined the differ-
ences in periodontal outcomes between canines uncov-
ered through excisional uncovering and the closed
eruption technique. Among the excluded studies, Oden-
APF

rick and Mod
eer18 detected a greater frequency of reces-

Tegsj€o et al,26 1984

sions (recession 5 gingival margin apical to the CEJ) in

teeth uncovered with excisional uncovering than in
those in which a closed eruption technique was used
(closed surgical: labial recession, 1/11; lingual recession,
RE

0/11; and radical exposure: labial recessions, 4/11;

lingual recessions, 3/11). However, these findings were
*Data are presented as means and standard errors; yRE control group; zAPF control group.

rather unreliable because of an inadequate sample

(including both incisors and canines, and palatal and
labial impactions), the chosen outcome measurements
Data are presented as means and standard deviations unless otherwise stated.
CTR

(frequency of recession rather than its measurement in

millimeters), and no statistical analysis.
Excisional uncovering resulted in a worse periodontal
outcome than an apically positioned flap: gingival
Significance

P \0.05

inflammation was more pronounced with the Gingival

only

Bleeding Index (radical exposure: 29%; apically posi-

tioned flap: 7%), and the width of keratinized gingiva
was more reduced (radical exposure: mean, 2.6 mm;
SD, 1.4; and apically positioned flap: mean, 4.3 mm;
Boyd,25 1984

SD, 1.8).26 As stated above, “radical exposure vs partial

PE

exposure” in Boyd's study25 could not be considered as

“excisional uncovering vs apically positioned flap,” since
“partial exposure” included partial excisional uncovering
as well as apically positioned flap.
Table IV. Continued

RE

None of the included studies compared the peri-

odontal outcome between canines uncovered with the
CTR

closed eruption technique and the apically positioned

flap technique. The most quoted study to prove the su-
Bone loss

periority in terms of periodontal health of the closed

technique over the apically positioned flap was that by
Vermette et al.23 However, even though their findings

American Journal of Orthodontics and Dentofacial Orthopedics April 2016  Vol 149  Issue 4
470 Incerti-Parenti et al

Table V. Quality assessment of the studies included in the review

Quality assessment Boyd,25 1984 Tegsj€o et al,26 1984 Kim et al,27 2007
Study design
Rating* II-1 II-2 II-2
Internal validity
Initial assembly of comparable groups:
For RCTs: adequate Yes NR NA (split-mouth design with
randomization, including patients serving as their own
first concealment and controls)
whether potential
confounders were
distributed equally among
groups.
For cohort studies: Yes NR NA (split-mouth design with
consideration of potential patients serving as their own
confounders with either controls)
restriction or measurement
for adjustment in the
analysis; consideration of
inception cohorts.
Maintenance of comparable Attrition: no Attrition: NR Attrition: NA
groups (includes attrition,
crossovers, adherence,
contamination).
Crossover: NA Crossover: NA Crossover: NA
Adherence: NA Adherence: NA Adherence: NA
Contamination: NA Contamination: NA Contamination: NA
Important differential loss to No NR No
follow-up or overall high
loss to follow-up.
Measurements: equal, reliable, Masking of outcome assessment: Masking of outcome assessment: Masking of outcome assessment:
and valid (includes masking NR NR NR
of outcome assessment).
Clear definition of Yes Yes Yes
interventions.
All important outcomes Yes Yes Yes
considered.
Analysis:
For cohort studies: NR No NA (split-mouth design)
adjustment for potential
confounders
For RCTs: intention-to- NR No NA (split-mouth design)
treat analysis
Rating* Fair Fair Fair
RCTs, Randomized controlled trials; NR, not reported; NA, not applicable.
*According to the US Preventive Services Task Force criteria.13

were considered unreliable because of the inclusion of
both canines and incisors, no direct comparison between
the 2 surgical techniques was done because of the sam-
ple's heterogeneity.
Limitations
The available evidence for this review came from only
3 studies. Sample sizes were rather small (20-50), and
none of the included studies provided an a priori sample
size calculation; this might cause an increased risk of
false-negative results and undermine the power of these
studies. Because the included studies (1 clinical trial
without random allocation and 2 retrospective cohort
studies) did not receive high scores for quality of evi-
dence, the risk of bias is high, and the evidence is rather
weak. Not every study included in the review established
pretreatment equivalence (age, sex, classification of oc-
clusion, length of treatment, and difficulty of surgical
exposure), thus increasing the risk of selection bias. A
detection bias may also exist because the periodontal
outcome assessors were not blinded to the treatments.
Finally, in the included studies, there was no mention

April 2016  Vol 149  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Incerti-Parenti et al
or evaluation of the surgeons' experience, which can
affect the periodontal outcome of the surgical uncover-
ing of unerupted maxillary canines.28
Review level
In addition to electronic databases, the reference lists
of relevant articles were consulted to identify articles
that should be included in the review. However, this
approach could lead to a citation bias because citing pre-
vious studies is not objective, and supportive and unsup-
portive studies may have been overcited. Unpublished
data sources (gray literature) were not searched. The po-
tential for publication bias was not assessed.
Implications for clinical practice
No clear evidence currently exists favoring one surgi-
cal technique over the others to uncover labially
impacted canines in terms of periodontal outcomes.
Current recommendations about which surgical proce-
dure is better for periodontal health are mainly based
on expert opinions. In this regard, the most quoted refer-
ence source is a study by Kokich.5 He stated that if there
is sufficient gingiva to provide at least 2 to 3 mm of
attached gingiva over the canine crown after its erup-
tion, any of the 3 techniques can be used; if the gingiva
is insufficient, the only technique that predictably will
produce more gingiva is an apically positioned flap.
However, without an evidence-based recommendation,
the choice of the method to uncover labially impacted
canines remains at the discretion of each practitioner.
Implications for future research
Since currently available studies provide insufficient
data to determine which surgical technique used to un-
cover labially impacted canines gives the best peri-
odontal outcome, further studies are recommended on
this topic. Specifically, we recommend that future
studies should meet the following criteria: (1) well-
designed, adequately powered, randomized controlled
trials (with adequate randomization); (2) split-mouth
design or consideration of potential confounders (eg,
age, sex, classification of occlusion, length of treatment,
and difficulty of surgical exposure); (3) outcomes: reces-
sion, periodontal probing depth, clinical attachment
level, width of keratinized gingiva, and crestal bone
loss; (4) blinding of outcome assessors; (5) outcomes as-
sessed 3 months after removal of the fixed appliances;
and (6) intention-to-treat analysis. Information
regarding the experience of the clinician performing
the surgery should also be provided. Since periodontal
outcome after canine uncovering with the closed tech-
nique has not been properly evaluated yet, research
American Journal of Orthodontics and Dentofacial Orthopedics
471
should specifically address the following issues: (1) peri-
odontal outcomes of canines uncovered with the closed
eruption technique; (2) comparisons between the closed
technique and excisional uncovering; and (3) compari-
sons between the closed technique and the apically posi-
tioned flap technique.
CONCLUSIONS
The current literature is insufficient to determine
which surgical procedure is better for periodontal health
to uncover labially impacted canines. Excisional uncov-
ering of labially impacted canines was reported to result
in less-favorable periodontal outcomes, whereas labially
impacted canines uncovered with the apically positioned
flap technique seemed to show periodontal outcomes
comparable with those of untreated teeth; none of the
included studies examined the periodontal outcome of
the closed eruption technique. Therefore, there is a def-
inite need for more well-designed research, especially
regarding the comparison between the closed technique
and the apically positioned flap technique.
REFERENCES
1. Kurol J. Early treatment of tooth-eruption disturbances. Am J Or-
thod Dentofacial Orthop 2002;121:588-91.
2. McDonald F, Yap WL. The surgical exposure and application of
direct traction of unerupted teeth. Am J Orthod 1986;89:331-40.
3. Ericson S, Kurol J. Early treatment of palatally erupting maxillary
canines by extraction of the primary canines. Eur J Orthod 1988;
10:283-95.
4. Jacoby H. The etiology of maxillary canine impactions. Am J Or-
thod 1983;84:125-32.
5. Kokich VG. Surgical and orthodontic management of impacted
maxillary canines. Am J Orthod Dentofacial Orthop 2004;126:
278-83.
6. Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Orthodontic
and periodontal outcomes of treated impacted maxillary canines.
Angle Orthod 2007;77:571-7.
7. 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.
8. Vanarsdall R, Corn H. Soft tissue management of labially posi-
tioned unerupted teeth. Am J Orthod 1977;72:53-64.
9. Silness J, L€
oe H. Periodontal disease in pregnancy II. Correlation
between oral hygiene and periodontal condition. Acta Odontol
Scand 1964;22:121-35.
10. L€oe H, Silness J. Periodontal disease in pregnancy. Acta Odontol
Scand 1963;21:533-51.
11. Ainamo J, Bay I. Problems and proposals for recording gingivitis
and plaque. Int Dent J 1975;25:229-35.
12. Armitage GC, Dickinson WR, Jenderseck RS, Levine SM,
Chambers DW. Relationship between the percentage of subgingi-
val spirochetes and the severity of periodontal disease. J Periodon-
tol 1982;53:550-6.
13. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM,
et al. Current methods of the US Preventive Services Task Force: a
review of the process. Am J Prev Med 2001;20(3 Suppl):21-35.
April 2016  Vol 149  Issue 4
472
14. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Golzsche PC,
Ioannidis JP, et al. The PRISMA statement for reporting systematic
reviews and meta-analyses of studies that evaluate health care in-
terventions: explanation and elaboration. PLoS Med 2009;6:
e1000100.
15. Caminiti MF, Sandor GK, Giambattistini C, Tompson B. Outcomes
of the surgical exposure, bonding and eruption of 82 impacted
maxillary canines. J Can Dent Assoc 1998;64:572-4,576-9.
16. Crescini A, Clauser C, Giorgetti R, Cortellini P, Pini Prato GP. Tun-
nel traction of infraosseous impacted maxillary canines. A three-
year periodontal follow-up. Am J Orthod Dentofacial Orthop
1994;105:61-72.
17. Gaulis R, Joho JP. The marginal periodontium of impacted upper
canines. Evaluation following various methods of surgical
approach and orthodontic procedures. SSO Schweiz Monatsschr
Zahnheilkd 1978;88:1249-61.
18. Odenrick L, Mod
eer T. Peridontal status following surgical-
orthodontic alignment of impacted teeth. Acta Odontol Scand
1978;36:233-6.
19. O'Dowling I. The unerupted maxillary canine—a post-surgical re-
view. J Ir Dent Assoc 2009;55:232-6.
20. Quirynen M, Op Heij DG, Adriansens A, Opdebeek HM, van
Steenberghe D. Periodontal health of orthodontically extruded
impacted teeth. A split-mouth long-term clinical evaluation. J Pe-
riodontol 2000;71:1708-14.
21. Soroka-Letkiewicz B, Zienkiewicz J, Dijakiewicz M. The use of the
“closed eruption” technique in the surgical-orthodontic treatment
April 2016  Vol 149  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Incerti-Parenti et al
of unerupted or impacted teeth. Ann Acad Med Gedan 2005;35:
97-108.
22. Szarmach IJ, Szarmach J, Waszkiel D, Paniczko A. Assessment
of periodontal status following the alignment of impacted per-
manent maxillary canine teeth. Adv Med Sci 2006;51(Suppl 1):
204-9.
23. Vermette ME, Kokich VG, Kennedy DB. Uncovering labially
impacted teeth: apically positioned flap and closed-eruption tech-
niques. Angle Orthod 1995;65:23-32.
24. 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.
25. Boyd R. Clinical assessment of injuries in orthodontic movement of
impacted teeth II: surgical recommendations. Am J Orthod 1984;
86:407-18.
26. Tegsj€o U, Valerius-Olsson H, Andersson L. Periodontal conditions
following surgical exposure of unerupted maxillary canines—a
long term follow-up study of two surgical techniques. Swed
Dent J 1984;8:257-63.
27. Kim SJ, Vanarsdall RL, Polson A, Katz S. Periodontal outcomes on
unerupted maxillary canines after apically positioned flaps [ab-
stract 1914]. J Dent Res 2007: (Spec Iss A).
28. Cortellini P, Pini Prato G. Coronally advanced flap and combina-
tion therapy for root coverage. Clinical strategies based on scien-
tific evidence and clinical experience. Periodontol 2000 2012;59:
158-84.