The International Journal of Periodontics & Restorative Dentistry

213

Tunnel Technique for the Treatment of

Impacted Mandibular Canines

Aldo Crescini, MD1 Despite its relatively low preva-

Tiziano Baccetti, DDS2 lence,1–4 impaction of a mandibular
Roberto Rotundo, DDS3 permanent canine is a clinical chal-
Evelyn Andrea Mancini, DDS4 lenge for dental practitioners, includ-
Giovanpaolo Pini Prato, MD, DDS5 ing both orthodontists and oral sur-
geons. The impacted mandibular
canine often presents with anatomic
and spatial features within the
The tunnel technique is a combined therapeutic approach that includes both sur-
mandibular bone that may create dif-
gical exposure of the impacted canine and orthodontic traction of the tooth to the
ficulties during orthodontic-surgical
center of the alveolar ridge, followed by final orthodontic alignment. A healthy
treatment4 (Fig 1). Further, transmi-
periodontium at the completion of therapy is the expected outcome. The tunnel
technique has been shown to be effective in the treatment of impacted maxillary
gration of the impacted mandibular
canines and can be suggested for the treatment of infraosseous impacted canines canine has been described not infre-
in the mandible when the corresponding primary canine is still present. Through quently because of the absence of a
the description of clinical cases, the management of the tunnel technique is midline suture in the mandible.5
reported. (Int J Periodontics Restorative Dent 2009;29:213–218.) Frequently, an infraosseous
impacted canine is associated with
the persistence of the corresponding
primary tooth in the dental arch. In this
case, after adequate space is created
orthodontically for the permanent
canine to erupt, the primary tooth is
extracted and the empty bony socket
can be used as a “tunnel” to guide the
1Visiting
impacted canine along an eruption
Professor, Department of Orthodontics, University of Siena, Siena, Italy.
2Researcher, Department of Orthodontics, University of Florence, Florence, Italy.
pathway that simulates the physio-
3Researcher, Department of Periodontology, University of Florence, Florence, Italy. logic one. In fact, ideally, successful
4Private Practice, Rosario, Argentina.
treatment should guide the tooth to
5Dean, Dental School, University of Florence, Florence, Italy.
erupt at the center of the alveolar
Correspondence to: Prof G. P. Pini Prato, viale Matteotti 11, 50121 Florence, Italy; ridge in a stable position, surrounded
fax: +390-55-572881; email: gpinipr@tin.it. by a healthy periodontium, as

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214
demonstrated through clinical investi-
gations of the combined orthodontic-
surgical treatment of impacted max-
illary canines.6–8 These studies have
shown that when a tooth is forced to
erupt in its ideal position, it will break
through the middle portion of the
gingiva, covering the crest of the
ridge. As a consequence, an ade-
quate amount of periodontal tissue
will be associated with the reposi-
tioned tooth at the completion of
therapy.
Although this concept has been
successfully applied in maxillae that
present with fully keratinized tissue on
the palatal side, the effort of guiding a
mandibular canine to the center of the
alveolar ridge becomes of paramount
importance because of the reduced
amount of keratinized tissue, especially
The International Journal of Periodontics & Restorative Dentistry
Fig 1 Impaction of mandibular canines.
(above left) Vertical position; (above right)
horizontal position; (below left) mesio-
inclination; (below right) distoinclination.
on the lingual side. Therefore, in the
presence of the primary canine, the
“tunnel technique” appears particu-
larly indicated for the forced eruption
of impacted mandibular canines.
Extraction of the primary tooth
creates a natural osseous tunnel, which
can be also augmented by means of
a low-speed bur in patients in whom
the tunnel does not reach the
impacted canine. The impacted tooth
is then moved orthodontically
between the cortical plates of the
mandibular bone, thus simulating the
normal eruption pathway.
The purpose of this study is to
illustrate the therapeutic outcomes of
the tunnel technique as a combined
orthodontic-surgical treatment in four
patients with impacted mandibular
canines.

d showed an adequate and healthy periodon-
Patient reports
Patient 1
This female patient was 15 years, 5
months old (Fig 2). Clinical inspection
revealed the persistence of the maxil-
lary primary canines and the mandibu-
lar left primary canine. A panoramic
radiograph showed that the three cor-
responding permanent canines were
present and impacted (Fig 2a). The
mandibular impacted canine was ver-
tically positioned in the region of the
emergence of the alveolar nerve. In
addition, its crown was located near
the roots of the lateral incisor.
The combined orthodontic-
surgical treatment proceeded similarly
to the treatment modality for
impacted maxillary canines. The
overall combined treatment is divided
into three steps: initial orthodontic
treatment, surgical treatment, and
215
Fig 2 Patient 1, a female who was 15
years and 5 months old. (a) Radiographic
aspects showing impactions of both maxil-
lary canines and the mandibular left canine.
(b) A full-thickness buccal flap was raised,
the mandibular left primary canine was
extracted, and buccal cortical bone plate
was removed to expose the permanent
canine. Fine mesh and a handmade chain
were fixed to the permanent tooth. (c) The
permanent tooth erupted properly and
tium after 2 years. (d) Final radiographic
view 2 years after treatment.
orthodontic traction with final ortho-
dontic alignment. Both maxillary
impacted canines were treated
according to the “tunnel technique.”
In the mandible, the same surgical
approach was performed following
orthodontic preparation to create ade-
quate space for tooth eruption.
After extraction of the mandibular
left primary canine, a full-thickness buc-
cal flap was elevated and the buccal
cortical bone plate was gently removed
Volume 29, Number 2, 2009
216
a b
c d
using diamond burs and curettes to
expose the cusp of the impacted
canine. The presence of a communi-
cation (tunnel) between the cusp of
the exposed tooth and the alveolar
socket was verified. An attachment
device (mesh) with a handmade metal
chain was passed through the osseous
tunnel and fixed to the crown of the
impacted canine on the buccal aspect
by means of bonding resin (Fig 2b).
The bonding agent was light-cured
for 60 seconds. Bonding was tested by
application of a traction force of 150 g
with a dynamometer. The chain
emerged from the socket of the pri-
mary tooth at the center of the ridge.
The buccal flap was sutured back into
The International Journal of Periodontics & Restorative Dentistry
its initial position. Ten days after
surgery, the sutures were removed and
orthodontic traction was begun by
means of a cantilever system. After
the canine had erupted into the oral
cavity, final derotation of the tooth and
leveling and alignment of the arch
were accomplished with a standard
edgewise technique.
Periodontal examination of the
repositioned mandibular canine was
performed at the end of the ortho-
dontic treatment. An adequate
amount of gingiva (4 mm) and a phys-
iologic crevice (1 mm) were present,
along with optimal alveolar bone sup-
port and no signs of recession at the
gingival margin (Figs 2c and 2d).
Fig 3 Patient 2, a 25-year-old woman. (a)
Following presurgical orthodontic treatment
to create sufficient space, full-thickness buc-
cal and lingual flaps were raised and the
mandibular left primary canine was extract-
ed. (b) The alveolar socket was enlarged
using diamond burs, and a sufficient
amount of the enamel surface was exposed.
An orthodontic button with a handmade
metallic chain was fixed to the cusp of the
tooth. (c) The flaps were sutured and the
handmade chain emerged at the center of
the alveolar ridge. (d) The permanent tooth
erupted properly, showing an adequate and
healthy periodontium after 1 year.
Patient 2
Patient 2 was a 25-year-old woman
(Fig 3). Clinical examination revealed
the presence of both maxillary primary
canines and the left mandibular pri-
mary canine. A panoramic radiograph
confirmed the presence of the corre-
sponding permanent maxillary
impacted canines and the left
mandibular impacted canine.
The tunnel technique was modi-
fied slightly to treat the mandibular
left impacted canine. After presurgical
orthodontic treatment was performed
to gain sufficient space, surgery was
undertaken. Full-thickness buccal and
lingual flaps were raised, and the left
 217

Fig 4 Patient 3, a 15-year-old woman. (a) The mandibular right

impacted canine was associated with an odontoma. (b) The primary
canine and the odontoma were removed and (c) an orthodontic but-
ton with a handmade metallic chain was fixed to the cusp of the
tooth. (d) The permanent tooth erupted at the center of the ridge.

mandibular primary canine was
extracted. The crown of the impacted
permanent canine was easily visual-
ized (Fig 3a). Because of the position
of the tooth at the center of the alve-
olar process and because of the thick-
ness of both buccal and lingual corti-
cal bone plates, the alveolar socket
was enlarged using diamond burs. In
this way, removal of the buccal bone
to expose the cusp of the impacted
tooth was avoided. An orthodontic
button with a handmade metallic chain
was bonded to the cusp of the tooth
(Fig 3b). The flaps were sutured and
the handmade chain emerged at the
center of the alveolar ridge (Fig 3c).
After 10 months, the permanent tooth
had erupted with an adequate and
healthy periodontium. Final ortho-
dontic treatment was performed to
align the teeth within the mandible
(Fig 3d).
Patient 3
Patient 3 was a 15-year-old female
(Fig 4) who needed orthodontic treat-
ment for tooth alignment. The
panoramic radiograph showed an
odontoma located between the
mandibular right primary canine and
the crown of the corresponding per-
manent canine (Fig 4a). The contralat-
eral tooth was fully erupted. Following
orthodontic preparation of the
mandible, the surgical procedure was

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218
performed. A full-thickness flap was
raised and the primary tooth was
extracted, exposing the odontoma.
The neoplasm was completely and
carefully removed and the buccal cor-
tical plate of the bone was maintained
as much as possible (Fig 4b). The alve-
olar socket (tunnel) and the empty
osseous socket left by the removal of
the odontoma allowed for exposure of
the impacted permanent canine. An
orthodontic button was bonded to the
tooth and the metal chain emerged at
the center of the alveolar ridge (Fig
4c). The flaps were sutured and the
sutures were removed 1 week later.
Two weeks after the surgical interven-
tion, orthodontic traction was started.
Approximately 8 months after surgery,
the permanent mandibular canine
erupted at the center of the ridge and
showed adequate periodontal tissues
(Fig 4d).
Conclusions
The combined orthodontic-surgical
“tunnel” technique has been shown to
be effective in the treatment of
impacted maxillary canines, resulting
in optimal orthodontic and periodontal
outcomes. Although this concept has
been successfully applied in maxillae
that present with fully keratinized tissue
on the palatal side, the effort of guiding
a mandibular canine to the center of the
alveolar ridge is more difficult because
of the reduced amount of keratinized
tissue, especially on the lingual side. In
the presence of the primary canine, the
“tunnel technique” appears particu-
larly indicated for the forced eruption
of mandibular impacted canines.
The International Journal of Periodontics & Restorative Dentistry
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