efectos periodontales de cirugía de caninos retenidos

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Periodontal status after surgical-orthodontictreatment 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 nal 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 ascertainedthequality of the studies. Results: Ninety-one studies were identied; 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 thecontrol group;

gingival recession,0.5 mm[SD, 1.0] vs1.5mm [SD, 0.8] in thecontrol group; and width of keratinizedgingiva,

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 ap had periodontal outcomes comparable with those of untreated teeth. Conclusions: The current liter-

ature is insufcient to determine which surgical procedure is better for periodontal health for uncovering labially

impacted canines. (Am J Orthod Dentofacial Orthop 2016;149:463-72)

Maxillary 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 deciency has been reported to play animportant role in the etiology of labial impactions:

Jacoby 4 found that only 17% of labially impacted ca-

nines had suf cient space to erupt. Orthodontic

mechanics to open the space for the canine crown might

lead to spontaneous eruption, but when space has beencreated and the canine does not erupt within a reason-

able time, surgical uncovering of the impacted toothshould be considered. Three techniques are generally

used to uncover labially impacted canines: excisionaluncovering (gingivectomy), apically positioned ap,and closed eruption.5

One fundamental indicator of a successful outcome

in the treatment of impacted canines is the nal 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 signicant differences in periodontal health be-

tween the open and closed techniques. Labial impac-tions seem to be more challenging to manage withoutadverse periodontal problems, and the surgical tech-nique used to uncover the canine is thought to be criticalfor the nal periodontal health because it affects theamount of attached gingiva over the tooth crown aftereruption.8 However, the actual periodontal impact of the surgical technique used to uncover labially impactedcanines is still unclear; to date, no systematic review has

been undertaken on this topic.

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.dAssistant professor, Department of Neuroscience, University of Padua, Padua,

Italy.eAssociate 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 Conicts 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, [email protected].

Submitted, February 2015; revised and accepted, October 2015.

0889-5406/$36.00

Copyright 2016 by the American Association of Orthodontists.

http://dx.doi.org/10.1016/j.ajodo.2015.10.019

463

SYSTEMATIC REVIEW


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The purpose of this study was to systematically re-

view the literature on the periodontal status of labially impacted canines after combined surgical-orthodontictreatment with different surgical approaches to clarify

whether there is suf

cient evidence to support one sur-gical technique over the others in terms of periodontalhealth.

MATERIAL AND METHODS

Eligibility was assessed on the basis of the followinginclusion 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 becauseof the anatomic differences in the keratinized tissues

between the palatal and labial mucosae. Studiesincluding both incisors and canines were excluded

because of the differences in the etiology of their im-pactions.

The intervention was combined surgical-orthodontictreatment 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 positionedap.

For comparison, when 1 technique was considered,the untreated contralateral side had to be used asthe control. When 2 surgical techniques werecompared, no untreated control group was required.

Outcomes; studies were considered for inclusion if atleast 1 of the following parameters was evaluated.

1. Plaque accumulation: plaque volume on thedental 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 inammation: assessment of the in-ammatory conditions of the gingiva can be

based on visual inspection and bleeding of thegingival 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 thegingival margin apical to the CEJ being positive,

and the gingival margin coronal to the CEJ beingnegative.

4. Periodontal probing depth: distance from thegingival margin to the location of the tip of aperiodontal probe inserted into the pocket.

5. Clinical attachment level: distance from the CEJto 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 betweenthe mucogingival junction and the projection onthe external surface of the bottom of the gingivalsulcus. 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 forinclusion if they fullled the population, intervention,comparisons, and outcomes criteria detailed above.

Information sources, search strategy, and study

selection

The following databases were searched from theirinception to January 2015 for relevant studies: PubMed,

Cochrane Central Register of Controlled Trials, LILACS,andScopus. There were no language restrictions. To iden-tify the relevant studies the following search strategy wasused: 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*)); lters: humans. Further studies were identied by hand searching the reference lists of all relevant articles.

The rst 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 andabstracts. For studies that appeared to be relevant, or

when a denite decision could not be made based onthe title or abstract alone, the full article was obtained

and independently examined by the reviewers fordetailed 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) rstauthor, year of publication, and location; (2) study

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design; (3) population characteristics (subjects enrolled,

mean age, and sex distribution); (4) intervention (surgi-cal exposure, orthodontic traction); (5) investigatedcomparisons; (6) follow-up of the study; (7) outcome

measures; (8) signi

cance 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.) wasconsulted.

Quality assessment in the studies

Two authors (V.C., A.G.) were blinded to the authorsand 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 tocriteria that varied depending on the study design), asstated by the U.S. Preventive Services Task Force(Table I).13 Disagreements were resolved through

consensus. The Spearman rank correlation coef cient was applied to evaluate the agreement between theraters.

Data synthesis

The ndings of the studies included in the systematicreview were gathered. A quantitative synthesis usingformal statistical techniques such as meta-analysis

seemed inappropriate because the selected studies were too few, with nonrandomized designs and a lackof homogeneity in the study settings. Therefore, a narra-tive synthesis was carried out.

RESULTS

Study selection and characteristics

The Figure shows the ow of the literature search ac-cording to the PRISMA format.14 The comprehensivesearch 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:

radical exposure (entire labial aspect of the crownexposed) and partial exposure (2-3 mm of keratinizedtissue maintained with either an apically positionedap 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 inammation, gingival recession, loss

of attachment, and width of attached gingiva) was eval-uated 6 to 24 months after removal of the xed appli-ances. The radical exposure group appeared to havemore gingival inammation, gingival recession, and

loss of attachment than both the contralateral untreatedcanine 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 untreatedcanines.

Kim et al27 evaluated the periodontal health of 23labially displaced canines, exposed with an apically posi-tioned ap technique. Periodontal outcomes, evaluatedat least 1 year after the surgery, were compared with

those of the contralateral untreated canines. Caninesexposed with an apically positioned ap, when

Table I. US Preventive Services Task Force rating of study quality

De nition 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 aw thatinvalidates its resultsy

Poor The study contains a fatal aw

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;ycriteria for grading internal validity (limited to the study designs

of the studies included in the review) were reported in Table V.

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1.5; SD, 0.8 mm), and reduced width of keratinizedgingiva (radical exposure: mean, 2.6; SD, 1.4 mm; andcontrol: 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. Cresciniet al,6,16 using a closed surgical technique with tunneltraction, at a 3-year follow-up found no signicant dif-ferences between the periodontal indexes of treated and

untreated canines, with a signicance 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) andcrestal 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 ndings from thesestudies were not conclusive because they included

both palatal and labial impactions6,16 or both incisorsand 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 signicant.

For the apically positioned ap 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 ap (both

were included in the “partial exposure” group); there-fore, no conclusion could be drawn regarding the peri-odontal status after the apically positioned apapproach compared with untreated canines. Among

the excluded studies, Vermette et al,23 who analyzedthe distance from the gingival margin to the CEJ (with

negative recording indicating a gingival margin locatedapically to the CEJ), found that teeth uncovered with anapically positioned ap showed more apical gingivalmargins on the mesial aspect (apically positioned ap:

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 ap: 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 ap: mean, 10.1 mm;SD, 1.00 mm; and control: mean, 9.5 mm; SD, 0.98 mm;

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

maxillary canine

Unilateral labially impacted

maxillary canine

Labially impacted maxillary canine

Surgical exposure and orthodontic

alignment of the impacted

canine

Surgical exposure of the impacted

canine performed between

1977 and 1979

Surgical exposure of the impacted

canine through APF

All appliances removed for a

minimum of 6 months

Minimum recall period of 1 year

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

window approach

RE: surgical uncovering; surgical

dressing for 1 week;

orthodontic traction

Full xed orthodontics; surgical

uncovering (APF); surgical

dressing for 1 week;

orthodontic traction

PE: 2-3 mm of keratinized tissue

maintained with either an APFor a tissue excision

APF: Surgical uncovering; surgical

dressing for 1 week;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 xed

appliances

30-56 after surgical exposure Minimum of 12 after surgery

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 ap; CTR , control group; PI , Plaque Index; GI , Gingival Index; GBI , Gingival

Bleeding Index; BT , bleeding tendency; REC , recession; PPD, pocket probingdepth; LA, loss of attachment; WAG,widthof attached gingiva; WKT ,

width of keratinized gingiva; lab, labial.




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Table IV. Periodontal outcomes reported in the included studies

Boyd,25 1984 Tegsj €o et al,26 1984

CTR RE PE

Signi cance only

P\0.05 CTR RE APF

Signi cance only

P\0.01 CTR *

PI 0.66 (SE, 0.143

GI NR NR NR RE.

CTR RE . PE

0.30 (SE, 0.108

BT NR NR NR RE . CTR

RE . PE

GBIb 7% 29% 7% RE . APF

RE . CTR

REC NR NR NR RE . CTR

RE . PE

1.5 mm

(SD, 0.8 mm)y

1.1 mm

(SD, 0.9 mm)z

0.5 mm

(SD, 1.0 mm)

0.9 mm

(SD, 1.2 mm)

RE . CTR

PPD

Buccal 1.6 mm

(SD, 0.6 mm)y

1.6 mm

(SD, 0.4 mm)z

1.2 mm

(SD, 0.4 mm)

1.4 mm

(SD, 0.4 mm)

APF . RE

CTR . RE

1.76 mm

(SE, 0.092 mm

Mesial 1.9 mm(SD, 0.6 mm)y

2.2 mm

(SD, 0.7 mm)z

2.4 mm(SD, 0.6 mm)

2.1 mm(SD, 0.5 mm)

NS

Palatal 1.9 mm

(SD, 0.5 mm)y

2.0 mm

(SD, 0.5 mm)z

2.1 mm

(SD, 0.5 mm)

2.0 mm

(SD, 0.5 mm)

NS

Distal 2.0 mm

(SD, 0.6 mm)y

2.1 mm

(SD, 0.6 mm)z

2.6

(SD, 0.6 mm)

2.2 mm

(SD, 0.6 mm)

NS

LA NR NR NR RE . CTR

RE . PE

WKG 4.1 mm

(SD, 1.5 mm)y

3.9 mm

(SD, 1.5 mm)z

2.6

(SD, 1.4 mm)

4.3 mm

(SD, 1.8 mm)

APF . RE

CTR . RE

WAG NR 0.0 mm 3.67 mm

(SD, 1.72 mm)

NR 3.73 mm

(SE, 0.254 mm

Clinical

crown

length

9.01 mm

(SE, 0.418 mm

Apr i l 2 0 1 6

Vol 1

4 9

I s s ue 4

Ame

r i c anJ our nal of O r t h od ont i c s and D

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P \0.02), increased probing attachment level on the

facial surface (apically positioned ap: mean,1.4 mm; SD, 1.15 mm; and control: mean,0.8 mm; SD, 0.62 mm; P \0.02), increased width of

attached gingiva on the facial surface (apically posi-tioned ap: mean, 3.5 mm; SD, 2.08 mm; and control:mean, 1.9 mm; SD, 0.68 mm; P \0.002), increased

probing bone level on the mesial aspect (apically posi-tioned ap: mean, 2.3 mm; SD, 0.57 mm; and control:mean, 1.8 mm; SD, 0.71 mm; P \0.007), the facialaspect (apically positioned ap: mean, 2.4 mm; SD,0.98 mm; and control: mean, 1.6 mm; SD, 0.61 mm;P \0.002), and the distal aspect (apically positionedap: 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 caninesand incisors, and the inadequate sample was the reasonfor 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 closederuption technique. Among the excluded studies, Oden-rick and Modeer18 detected a greater frequency of reces-sions (recession 5 gingival margin apical to the CEJ) in

teeth uncovered with excisional uncovering than inthose in which a closed eruption technique was used(closed surgical: labial recession, 1/11; lingual recession,0/11; and radical exposure: labial recessions, 4/11;lingual recessions, 3/11). However, these ndings were

rather unreliable because of an inadequate sample(including both incisors and canines, and palatal and

labial impactions), the chosen outcome measurements(frequency of recession rather than its measurement inmillimeters), and no statistical analysis.

Excisional uncovering resulted in a worse periodontal

outcome than an apically positioned ap: gingivalinammation was more pronounced with the Gingival

Bleeding Index (radical exposure: 29%; apically posi-tioned ap: 7%), and the width of keratinized gingiva

was more reduced (radical exposure: mean, 2.6 mm;SD, 1.4; and apically positioned ap: mean, 4.3 mm;

SD, 1.8).26

As stated above, “radical exposure vs partialexposure” in Boyd's study 25 could not be considered as

“excisional uncovering vs apically positioned ap,” since“partial exposure” included partial excisional uncoveringas well as apically positioned ap.

None of the included studies compared the peri-odontal outcome between canines uncovered with the

closed eruption technique and the apically positionedap technique. The most quoted study to prove the su-periority in terms of periodontal health of the closedtechnique over the apically positioned ap was that by

Vermette et al.23 However, even though their ndings T a b l e

I V .

C o n t i n u e d

B o y d , 2

5 1 9

8 4

T e g s j € o e t a l , 2 6

1 9 8 4

K i m e t a l , 2 7

2 0 0 7

C T R

R E

P E

S i g n i c a n c e

o n l y

P \ 0 . 0

5

C T R

R E

A P F

S i g n i c a n c e

o n l y

P \ 0 . 0

1

C T R *

A P F *

S i g n i c a n c e

o n l y

P \ 0 . 0

5

B o n e l o s s

1 . 0 8 m m

( S E , 0 . 1 7 3 m m )

1 . 3 6 m m

( S E , 0 . 1 8 5 m m )

N S

D a t a a r e p r e s e n t e d a s m e a n s a n d s t a n d a r d d e v i a t i o n s u n l e s s o t h e r w i s e s t a t e d .

C T R , c o n t r o l g r o u p ; R E , r a d i c a l e x p o s u r e ; P

E , p a r t i a l e x p o s u r e ; A P F , a p i c a l l y p o s i t i o n e d a p ; P I , P l a q u e I n d e x ; G I , G i n g i v a l I n d e x ; B T , b

l e e d i n g t e n d e n c y ; G B I b ,

G i n g i v a l B l e e d i n g I n d e

x ( b u c c a l ) ; R E C ,

R e c e s s i o n ; P P D , p o c k e t p r o b i n g d e p t h ; L A

, l o s s o f a t t a c h m e n t ; W K T , w i d t h o f k e r a t i n i z

e d g i n g i v a ; W A G , w i d t h o f a t t a c h e d g i n g i v a ; N R , n o t r e p o r t e d ; N S , n o t s i g n i c a n t .

* D a t a a r e p r e s e n t e d a s m e a n s a n d s t a n d a r d e r r o r s ;

y R E c o n t r o l g r o u p ;

z A P F c o n t r o l g r o u p .




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were considered unreliable because of the inclusion of both canines and incisors, no direct comparison betweenthe 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), andnone of the included studies provided an a priori samplesize 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 cohortstudies) 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 establishedpretreatment equivalence (age, sex, classication of oc-clusion, length of treatment, and dif culty of surgicalexposure), thus increasing the risk of selection bias. Adetection bias may also exist because the periodontaloutcome assessors were not blinded to the treatments.

Finally, in the included studies, there was no mention

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

randomization, including

rst concealment and

whether potential

confounders were

distributed equally among

groups.

Yes NR NA (split-mouth design with

patients serving as their own

controls)

For cohort studies:

consideration of potential

confounders with either

restriction or measurement

for adjustment in the

analysis; consideration of inception cohorts.

Yes NR NA (split-mouth design with

patients serving as their own

controls)

Maintenance of comparable

groups (includes attrition,

crossovers, adherence,

contamination).

Attrition: no Attrition: NR Attrition: NA

Crossover: NA Crossover: NA Crossover: NA

Adherence: NA Adherence: NA Adherence: NA

Contamination: NA Contamination: NA Contamination: NA

Important differential loss to

follow-up or overall high

loss to follow-up.

No NR No

Measurements: equal, reliable,

and valid (includes masking

of outcome assessment).

Masking of outcome assessment:

NR


NR


NR

Clear denition of interventions.

Yes Yes Yes

All important outcomes

considered.

Yes Yes Yes

Analysis:

For cohort studies:

adjustment for potential

confounders

NR No NA (split-mouth design)

For RCTs: intention-to-

treat analysis

NR No NA (split-mouth design)

Rating* Fair Fair Fair

RCTs, Randomized controlled trials; NR , not reported; NA, not applicable.

*According to the US Preventive Services Task Force criteria.13




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or evaluation of the surgeons' experience, which can

affect the periodontal outcome of the surgical uncover-ing of unerupted maxillary canines.28

Review levelIn addition to electronic databases, the reference lists

of relevant articles were consulted to identify articlesthat should be included in the review. However, thisapproach could lead to a citation bias because citing pre-

vious studies is not objective, and supportive and unsup-portive studies may have been overcited. Unpublisheddata 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 basedon expert opinions. In this regard, the most quoted refer-ence source is a study by Kokich.5 He stated that if there

is suf cient 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 gingivais insuf cient, the only technique that predictably willproduce more gingiva is an apically positioned ap.

However, without an evidence-based recommendation,

the choice of the method to uncover labially impactedcanines remains at the discretion of each practitioner.

Implications for future research

Since currently available studies provide insuf cientdata 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. Specically, we recommend that futurestudies should meet the following criteria: (1) well-designed, adequately powered, randomized controlledtrials (with adequate randomization); (2) split-mouth

design or consideration of potential confounders (eg,age, sex, classication of occlusion, length of treatment,and dif culty of surgical exposure); (3) outcomes: reces-sion, periodontal probing depth, clinical attachmentlevel, width of keratinized gingiva, and crestal boneloss; (4) blinding of outcome assessors; (5) outcomes as-sessed 3 months after removal of the xed appliances;

and (6) intention-to-treat analysis. Informationregarding the experience of the clinician performingthe surgery should also be provided. Since periodontaloutcome after canine uncovering with the closed tech-nique has not been properly evaluated yet, research

should specically address the following issues: (1) peri-

odontal outcomes of canines uncovered with the closederuption technique; (2) comparisons between the closedtechnique and excisional uncovering; and (3) compari-

sons between the closed technique and the apically posi-tioned ap technique.

CONCLUSIONS

The current literature is insuf cient to determine

which surgical procedure is better for periodontal healthto uncover labially impacted canines. Excisional uncov-ering of labially impacted canines was reported to resultin less-favorable periodontal outcomes, whereas labially

impacted canines uncovered with the apically positionedap 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 ap 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

controlledtrial. Am J OrthodDentofacial Orthop2013;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,MulrowCD, 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.




10/10

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. Outcomesof 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, Modeer 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

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 ap 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. BoydR. 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 onunerupted maxillary canines after apically positioned aps [ab-

stract 1914]. J Dent Res 2007: (Spec Iss A).

28. Cortellini P, Pini Prato G. Coronally advanced ap and combina-

tion therapy for root coverage. Clinical strategies based on scien-

tic evidence and clinical experience. Periodontol 2000 2012;59:

158-84.



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