Guidelines for Impacted Canine Treatment. 서울유펜치과 김수진 DDS, MS, Ph.D

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1 Guidelines for Impacted Canine Treatment 서울유펜치과 김수진 DDS, MS, Ph.D

2 University of Pennsylvania Department of Orthodontics Research Focus Periodontal consideration in orthodontics Transverse Analysis based on PA Ceph -RPE, SARPE Periodontal status following surgical-orthodontic alignment of unerupted maxillary canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA

3 Contents Introduction Background Previous studies Maxillary canine impaction etiology, incidence Surgical Techniques APF, CE APF VS CE University of Pennsylvania Study Case A.C., R.C. Summary

4 2006 년대한치과교정학회정기총회및제 39 회학술대회

5 85th General Session & Exhibition of the IADR New Orleans, Louisiana March 2007

6 85th General Session & Exhibition of the IADR New Orleans, Louisiana March 2007

7 Introduction Etiology Incidence

8 Maxillary Canine Eruption and Deviation Eruption - the longest period of development - deepest area of development - most difficult eruption path of all teeth most likely to unerupted and impacted other than third molars Deviation crowding -> erupts more labial and higher in alveolar process adequate space -> abnormal buccally displaced eruption path Ngan P, Hornbrook R Seminars in Orthodontic 2005 Sep:11(3):

9 Etiology of maxillary canine impaction Etiology - mulifactorial - wide variety of genetic, systemic and local factors Complications of canine impaction - resorption of adjacent root - malposition, internal resorption - external resorption - necessity for careful evaluation and assessment of canines during permanent dentition in child Ngan P, Hornbrook R Seminars in Orthodontic 2005 Sep:11(3):

10 Incidence of Maxillary Canine Impaction Incidence Ectopic eruption and impaction of maxillary permanent canines - 2 % of orthodontic population ~ 3% of prevalence reported Female:Males 2~3 : 1 Palatal:labial 2~3 : 1 85%: 15% 8% of all patients with maxillary impacted canines bilateral impaction University of Pennsylvania labially impacted maxillary canines : about 1% of orthodontic population ( )

11 Importance of maxillary canines Importance of maxillary canine -functional occlusion scheme - contribution to the dental appearance of the patient - size and root length - role in establishing normal arch form Approach - accepted the challenge of impacted canine - recommended many methods and ideas for speedy and effective resolution

12 Labial Impaction In the past, more attention to palatally impacted canines and less to buccal canine Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod Jul;72(1):53-64 McBride, L.J., Traction--a surgical/orthodontic procedure. Am J Orthod, (3): p Periodontal problems associated with severely impacted labial canines Labially impacted teeth is the most difficult to manage without causing adverse periodontal problem Successful treatment of labially positioned teeth by proper management of the tissues attached to them

13 Palatal Impaction 1976 Wisth PJ, Norderval K, Booe OE. Comparison of two surgical methods in combined surgical-orthodontic correction of impacted maxillary canines. Acta Odontol Scand. 34(1): Becker, A., P. Smith, and R. Behar, The incidence of anomalous maxillary lateral incisors in relation to palatally-displaced cuspids. Angle Orthod, 51(1): p Becker, A., D. Kohavi, and Y. Zilberman, Periodontal status following the alignment of palatally impacted canine teeth. Am J Orthod, (4): p Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal and periodontal reactions to orthodontic alignment of palatally impacted canines. Angle Orthod. 1994;64(4): Bishara, S.E., Clinical management of impacted maxillary canines. Semin Orthod, 4(2): p Blair GS, Hobson RS, Leggat TG. Posttreatment assessment of surgically exposed and orthodontically aligned impacted maxillary canines. Am J Orthod Dentofacial Orthop. 113(3): Suri S, Utreja A, Rattan V. Orthodontic treatment of bilaterally impacted maxillary canines in an adult. Am J Orthod Dentofacial Orthop. 2002;122(4):

14 Labial Impaction 1977 Vanarsdall, R.L. and H. Corn, Soft-tissue management of labially positioned unerupted teeth. Am J Orthod, 72(1): p McBride, L.J., Traction--a surgical/orthodontic procedure. Am J Orthod, 76(3): p Kohavi, D., Y. Zilberman, and A. Becker, Periodontal status following the alignment of buccally ectopic maxillary canine teeth. Am J Orthod, 85(1): p Artun, J., S.K. Osterberg, and D.R. Joondeph, Long-term periodontal status of labially erupted canines following orthodontic treatment. J Clin Periodontol, 13(9): p Vermette, M.E., V.G. Kokich, and D.B. Kennedy, Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques. Angle Orthod, 65(1): p ; 2002 Becker, A., et al., Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation. Am J Orthod Dentofacial Orthop, 122(1): p Chaushu, S., et al., Periodontal status following surgical-orthodontic alignment of impacted central incisors with an open-eruption technique. Eur J Orthod, (6): p

15 Palatal Impaction 2006 Szarmach IJ, Szarmach J, Waszkiel D. Complications in the course of surgical-orthodontic treatment of impacted maxillary canines. Adv Med Sci. 51 Suppl 1: Szarmach IJ, Szarmach J, Waszkiel D, Paniczko A. Assessment of periodontal status following the alignment of impacted permanent maxillary canine teeth. Adv Med Sci. ;51 Suppl 1: Ngom PI, Benoist HM, Diagne F, Diop L, Diallo B. [Surgical and Orthodontic Treatment of Impacted Canines: A Clinical Report] Odontostomatol Trop. 29(116):23-9. French Ling KK, Ho CT, Kravchuk O, Olive RJ. Comparison of surgical and non-surgical methods of treating palatally impacted canines. I. Periodontal and pulpal outcomes. Aust Orthod J. 23(1): Caprioglio A, Siani L, Caprioglio C. Guided eruption of palatally impacted canines through combined use of 3-dimensional computerized tomography scans and the easy cuspid device. World J Orthod. 8(2): Review Schmidt AD, Kokich VG. Periodontal response to early uncovering, autonomous eruption, and orthodontic alignment of palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. ;131(4): Celli D, Catalfamo L, Deli R. Palatally impacted canines: the double traction technique. Prog Orthod. 8(1): English, Italian.

16 Labial Impaction 2005 Lin JJ. Do teeth want to be straight? A nonsurgical approach to unerupted teeth. World J Orthod. 6(3): Milberg DJ. Labially impacted maxillary canines causing severe root resorption of maxillary central incisors. Angle Orthod Jan;76(1): Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Pre-treatment radiographic features for the periodontal prognosis of treated impacted canines. J Clin Periodontol. 34(7): Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Short- and long-term periodontal evaluation of impacted canines treated with a closed surgical-orthodontic approach. J Clin Periodontol Mar;34(3): Epub 2007 Jan Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Orthodontic and periodontal outcomes of treated impacted maxillary canines. Angle Orthod Jul;77(4):571-7.

17 Localization of Impacted Maxillary Canine Oral Surg Oral Med Oral Pathol Oral Radiol Endod May 14; Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone-beam computed tomography. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. The aim of this study : to investigate with cone-beam computed tomography (CBCT) the locations of impacted maxillary canines and resorption of neighboring incisors. STUDY DESIGN: Two hundred ten impacted maxillary canines were analyzed using CBCT images. The locations of the impacted canines were assessed and angular and linear measurements were taken using NewTom proprietary software. In addition, root resorption of neighboring incisors was investigated. 45.2% were impacted buccal-labially, 40.5% were impacted palatally, and 14.3% in the midalveolus. The locations varied: mesial-labial impaction (n = 67), mesial-palatal impaction (n = 74), in situ impaction (n = 31), distal impaction (n = 12), horizontal impaction (n = 18), and inverted impaction (n = 8). CONCLUSION: The location of impacted maxillary canines varies greatly in 3 planes, and the resorption of neighboring permanent incisors is common.

18 ORTHODONTICS

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20 Background Surgical Technique Apically Positioned Flap Closed Eruption Technique

21 Surgical Technique Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop Sep;126(3): techniques for uncovering labially impacted maxillary canines Simple exposure Apically positioned flap technique Closed eruption technique 4 criteria to determine the correct method Labiolingual position of the impacted canine crown Vertical position of the tooth relative to the mucogingival junction Amount of gingiva in the area of the impacted canine Mesiodistal position of the canine crown Split-thickness pedicle reflected from the edentulous area, saving as much gingiva as possible Elevating a flap, placing an attachment on the impacted tooth, returning the flap to its original location

22 Surgical Technique Apically Positioned Graft Technique Closed Eruption Technique Pictures by Courtesy of Dr. Jolley U of Penn

23 Surgical Technique Simple exposure labially positioned Coronal to M-G junction Open eruption Apically positioned flap 4 criteria to determine the correct method a. Labiolingual position of the impacted canine crown b. Vertical position of the tooth relative to the mucogingival junction c. Amount of gingiva in the area of the impacted canine d. Mesiodistal position of the canine crown Closed eruption below M-G junction Insufficient ginigiva above M-G junction & in alveolus Kokich VG. AJODO 2004 Sep;126(3):

24 Surgical Technique Uncovering labially impacted maxillary canine - Apically positioned flap technique VS Closed eruption technique - Conflicting reports regarding periodontal and esthetic outcomes Open Eruption technique = Apically Positioned Flap technique Open eruption technique : incising all of the overlying tissue (hard and soft) the tooth can be left open to the oral cavity. Apically position graft technique (partial thickness flap): no bone is left exposed

25 Research Background Previous Studies Apically Positioned Flap VS Closed Eruption

26 Apically Positioned Graft 1977 Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod Jul;72(1):53-64 > 75 labially impacted teeth, uncovered using a split-thickness apically positioned flap - found no marginal bone loss or gingival recession after orthodontic treatment Surgical procedure - incorporate a means of providing attached gingiva over the tooth - control inflammation and prevent muscles of the face from detaching the marginal periodontal tissue from the tooth

27 Apically Positioned Graft Graber TM, Vanarsdall RL Orthodontics: Current Principles and Techniques, 4th Edi St Louis: Mosby; 2005, p 922 closed eruption technique always prolongs the treatment time, requires additional surgical procedure, diminishes control of tooth movement, and may cause adverse periodontal responses

28 Apically Positioned Flap VS Closed Eruption 1995 Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques. Angle Orthod. 1995;65(1):23-32

29 Closed Eruption Technique Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S. Closed-eruption surgical technique for impacted maxillary incisors: A postorthodontic periodontal evaluation. AJODO 2002 Jul;122(1): impacted maxillary central incisor patients Statistically significant differences in some of the periodontal parameters measured Overall clinical consequences of orthodontic alignment of impacted incisors are minimal Open Eruption technique = Apically Positioned Flap technique Open Eruption Technique Chaushu S, Brin I, Ben-Bassat Y, Zilberman Y, Becker A. Periodontal status following surgical-orthodontic alignment of impacted central incisors with an open-eruption technique. Eur J Orthod Dec;25(6): impacted maxillary central incisors patients : split mouth design Open-eruption technique: long-term negative esthetic and periodontal effects on the treated tooth : possible need for additional periodontal procedures to improve the esthetics and periodontal health of the treated teeth

30 Periodontal status following surgical-orthodontic alignment of unerupted maxillary canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Research Background: Uncovering labially impacted maxillary canine - Apically positioned graft technique and Closed eruption technique Closed Eruption Technique - By some to be the best method of uncovering labially impacted teeth - Evaluation of periodontal status demonstrated inconsistent conclusions Minimal research regarding Apically positioned graft (APG) technique Periodontal and esthetic outcome not properly evaluated Some studies failed to differentiate open eruption technique from APF Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod Jul;72(1): APG procedure in uncovering impacted teeth helps prevent marginal bone loss and gingival recession

31 Periodontal status following surgical-orthodontic alignment of unerupted maxillary canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA PURPOSE To investigate periodontal, endodontic, and esthetic outcome in orthodontic patients treated for unerupted maxillary canines using apically positioned graft technique NULL HYPOTHESIS There is no statistically significant differences between the treated and control teeth in the esthetic and periodontal outcome measured at α=0.05

32 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Sample 20 orthodontic patients, with a total of 23 surgically treated unerupted maxillary canines Dept of Orthodontics, School of Dental Medicine, University of Pennsylvania, Penn Dental Network, Two private practices Inclusion criteria unerupted maxillary canines initial radiographic records available impaction treated by apically positioned graft technique minimum recall period of 1 year after the surgery

33 Surgical-Orthodontic Procedure Apically Positioned Graft Technique Surgical-Orthodontic Treatment Full fixed orthodontics Apically positioned partial thickness pedicle graft - crown of the impacted tooth clinically visible and accessible at the completion of the surgery 1 week later - an attachment bonded and eruptive traction applied Tooth brought into the arch by orthodontic extrusive traction by power thread to the base arch wire Pictures by Courtesy of Dr. Jolley University of Pennsylvania 1 Week Postop

34 Evaluation of Outcomes Parameters examined Periodontal evaluation - Plaque index, Gingival index, Probing depth, Attached gingiva width, Clinical crown length Esthetic evaluation -Texture of gingiva, Scarring, Recession, Discoloration Radiographic evaluation - Crestal alveolar bone level Bony support Bony defect Obliteration Radiolucency Split-mouth design - treated side is compared with the unaffected side in the same mouth

35 RESULTS

36 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Plaque index Gingival index Statistically not significant by Paired two-tailed t-test at P=0.05 Treated Contralateral Difference Periodontal measurements Plaque index (score) Mean 0.75 (0.150)* 0.66 (0.143) NS** Mesial 0.82 (0.154) 0.70 (0.161) NS Comparison of Groups Labial 0.70 (0.166)* 0.70 (0.166) NS Distal 0.70 (0.142) 0.64 (0.147) NS Palatal 0.58 (0.150)* 0.53 (0.151) NS Gingival index (score) Mean 0.43 (0.120)* 0.30 (0.108) NS Mesial 0.52 (0.174) 0.41 (0.150) NS Labial 0.35 (0.119)* 0.23 (0.106) NS Distal 0.47 (0.151) 0.23 (0.106) NS Index Score PI GI Treated Contralateral Periodontal Index Palatal 0.35 (0.119)* 0.35 (0.119) NS * :Presented as mean (standard error) **: Statistically not significant by Paired two-tailed t-test at P=0.05 Comparison between treated and contralateral teeth PI: Plaque index GI: Gingival index

37 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Probing Depth Width of Attached Gingiva Clinical Crown Length Statistically not significant by Paired two-tailed t-test at P=0.05 Treated Contralateral Difference Comparison of Groups Probing depth (mm) Mean 1.86 (0.105)* 1.76 (0.092) NS * * Mesiolabial 2.20 (0.142) 2.23 (0.114) NS Midlabial 1.23 (0.114)* 1.23 (0.129) NS Distolabial 2.05 (0.176) 2.20 (0.162) NS Mesiopalatal 2.14 (0.200)* 1.86 (0.170) NS Midpalatal 1.73 (0.136) 1.52 (0.124) NS Distopalatal 1.82 (0.196)* 1.52(0.151) NS Width of attached gingiva (mm) 4.15 (0.410) 3.73 (0.254) NS Clinical crown length (mm) 9.14 (0.371)* 9.01(0.418) NS * :Presented as mean (standard error) **: Statistically not significant by Paired two-tailed t-test at P=0.05 mm PD AG CCL Treated Contralateral Periodontal Parameter Comparison between treated and contralateral teeth PD: Probing Depth AG: Attached Gingiva CCL: Clinial Crown Length

38 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Esthetic Evaluation Texture of gingiva Scarring Discoloration Recession Clinical appearance Treated Contralateral Difference Texture of gingiva NS** Good 23* 23 Acceptable 0 0 Not good 0 0 Gingival scarring NS No Slight 5 0 Significant 0 0 Discoloration 0 0 NS Recession 0 0 NS * :Presented as number of teeth **: Statistically not significant by Chi-square test at P=0.05

39 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Radiographic Evaluation Statistically not significant by Paired two-tailed t-test at P=0.05 Bony Support Crestal Alveolar Bone Level % mm LOWER 95% CI MEAN UPPER 95% CI Treated Contralateral LOWER 95% CI MEAN UPPER 95% CI Treated Contralateral Treated Contralateral Difference Parametric variables Bony support (%) Bone level (CEJ~alveolar crest) (1.371) * 1.36 (0.185) ** (1.350) 1.08 (0.173) NS*** NS*** Pathology evaluation Defect 0**** 0 Obliteration 0 0 Radiolucency 0 0 * :Presented as mean (standard error), % **: Presented as mean (standard error), mm ***: Statistically not significant by Paired two-tailed t-test at P=0.05 ****: indicated as number of teeth

40 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Radiographic Evaluation Percentage bone support = apex-crest of interseptal bone X 100 apex-cej apex-cej apex-cej apex -crest of interseptal bone Crestal alveolar bone level : CEJ ~ crest of interseptal bone Becker, A., D. Kohavi, et al "Periodontal status following the alignment of palatally impacted canine teeth." Am J Orthod 84(4): Kohavi D, Zilberman Y, Becker A Periodontal status following the alignment of buccally ectopic maxillary canine teeth. Am J Orthod.;85(1):78-82

41 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Radiographic Evaluation Statistically not significant by Paired two-tailed t-test at P=0.05 Bony Support Crestal Alveolar Bone Level % mm LOWER 95% CI MEAN UPPER 95% CI Treated Contralateral LOWER 95% CI MEAN UPPER 95% CI Treated Contralateral Treated Contralateral Difference Parametric variables Bony support (%) Bone level (CEJ~alveolar crest) (1.371) * 1.36 (0.185) ** (1.350) 1.08 (0.173) NS*** NS*** Pathology evaluation Defect 0**** 0 Obliteration 0 0 Radiolucency 0 0 * :Presented as mean (standard error), % **: Presented as mean (standard error), mm ***: Statistically not significant by Paired two-tailed t-test at P=0.05 ****: indicated as number of teeth

42 A.C. Caucasian Initial Records: Age: 12Y5M Pictures by Courtesy of Dr. Pershing University of Pennsylvania

43 Follow-up for Surgery Obliteration, Bony defect, Radiolucency Not Present Treated by APF Age at surgery: 13y 8m Period after surgery:17m Recall from debonding: 3m Contralateral Texture of gingiva Scarring Discoloration Recession Clinically indistinguishable from control

44 R.C. Caucasian Initial Records: Age: 18Y Pictures by Courtesy of Dr. Degroote University of Pennsylvania

45 Follow-up for Surgery Obliteration, Bony defect, Radiolucency Not Present Age at surgery: 18y8m Period after surgery:1y1m Recall from debonding: 1m Contralateral Treated by APF Texture of gingiva Scarring Discoloration Recession Clinically indistinguishable from control

46 Clinical Examination Texture of gingiva Scarring Discoloration Recession Age at surgery: 14y5m Period after surgery: 22m Recall from debonding: 11m Age at surgery: 15y4m Period after surgery:13m Recall from debonding: 50m Treated canine : APF Contralateral Age at surgery: 12y9m Period after surgery: 34m Recall from debonding:10m Treated canine : APF Contralateral Clinically indistinguishable from control

47 Radiographic Evaluation Treated canine : APF Contralateral Treated canine : APF Contralateral Recall periapical radiographs of labially impacted canines uncovered with an apically positioned flap (APF) in comparison with its control The differences in calculated bony support were not statistically significant None of the treated and control canines demonstrated obliteration, bony defect, or radiolucency

48 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Conclusion Ectopically positioned teeth treated by apically positioned flap techniques Orthodontically moved control teeth in the same patient 1. Periodontal outcome - control had normal values - no significant differences : plaque index, gingival index, pocket depth, attached gingiva, and clinical crown length 2. Esthetic outcome - no significant differences - texture of gingiva, recession, scarring, and discoloration 3. Radiographic outcome - no significant differences - crestal alveolar bone level, bony support, pulpal and periapical characteristics

49 Periodontal status following surgical-orthodontic alignment of unerupted maxillalry canines treated with an Apically Positioned Graft Technique Soo-Jin Kim, Robert L. Vanarsdall, Alan Polson, Solomon Katz University of Pennsylvania, School of Dental Medicine, Philadelphia, USA Conclusion Ectopically positioned maxillary canines treated by apically positioned flap techniques had satisfactory results for periodontal, radiographic, esthetic, and endodontic outcomes compared with orthodontically moved control teeth in the same patient

50 Summary Unerupted Maxillary Canines - most commonly impacted other than third molars - any potentially harmful sequel warrant intervention - orthodontist and surgeon : choose surgical procedure that incorporate a means of providing attached gingiva over the tooth

51 Summary Present study investigated results of successful resolution of the impaction of maxillary canines Apically Positioned Graft Technique provides attached gingiva on the tooth control inflammation prevent the facial muscles from detaching the marginal periodontal tissue from the tooth prevent marginal bone loss and gingival recession