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

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

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

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

2006 년대한치과교정학회정기총회및제 39 회학술대회

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

Introduction Etiology Incidence

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):152-163

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):152-163

Incidence of Maxillary Canine Impaction Incidence Ectopic eruption and impaction of maxillary permanent canines - 2 % of orthodontic population - 0.9 ~ 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 (2003 2006)

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

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. 1977 Jul;72(1):53-64 McBride, L.J., Traction--a surgical/orthodontic procedure. Am J Orthod, 1979 76(3): p. 287-99. 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

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):53-7. 1981 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. 24-9. 1983 Becker, A., D. Kohavi, and Y. Zilberman, Periodontal status following the alignment of palatally impacted canine teeth. Am J Orthod, 1983. 84(4): p. 332-6. 1994 Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal and periodontal reactions to orthodontic alignment of palatally impacted canines. Angle Orthod. 1994;64(4):257-64 1998 Bishara, S.E., Clinical management of impacted maxillary canines. Semin Orthod, 4(2): p. 87-98. 1998 Blair GS, Hobson RS, Leggat TG. Posttreatment assessment of surgically exposed and orthodontically aligned impacted maxillary canines. Am J Orthod Dentofacial Orthop. 113(3):329-32. 2002 Suri S, Utreja A, Rattan V. Orthodontic treatment of bilaterally impacted maxillary canines in an adult. Am J Orthod Dentofacial Orthop. 2002;122(4):429-37.

Labial Impaction 1977 Vanarsdall, R.L. and H. Corn, Soft-tissue management of labially positioned unerupted teeth. Am J Orthod, 72(1): p. 53-64. 1979 McBride, L.J., Traction--a surgical/orthodontic procedure. Am J Orthod, 76(3): p. 287-99. 1984 Kohavi, D., Y. Zilberman, and A. Becker, Periodontal status following the alignment of buccally ectopic maxillary canine teeth. Am J Orthod, 85(1): p. 78-82. 1986 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. 856-61. 1995 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. 23-32; 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. 9-14. 2003 Chaushu, S., et al., Periodontal status following surgical-orthodontic alignment of impacted central incisors with an open-eruption technique. Eur J Orthod, 2003. 25(6): p. 579-84.

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 1:217-20. 2006 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 1:204-9. 2006 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. 2007 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):1-7. 2007 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):109-21. Review. 2007 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):449-55. 2007 Celli D, Catalfamo L, Deli R. Palatally impacted canines: the double traction technique. Prog Orthod. 8(1):16-26. English, Italian.

Labial Impaction 2005 Lin JJ. Do teeth want to be straight? A nonsurgical approach to unerupted teeth. World J Orthod. 6(3):248-57. 2006 Milberg DJ. Labially impacted maxillary canines causing severe root resorption of maxillary central incisors. Angle Orthod. 2006 Jan;76(1):173-6. 2007 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):581-7. 2007 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. 2007 Mar;34(3):232-42. Epub 2007 Jan 25. 2007 Crescini A, Nieri M, Buti J, Baccetti T, Pini Prato GP. Orthodontic and periodontal outcomes of treated impacted maxillary canines. Angle Orthod. 2007 Jul;77(4):571-7.

Localization of Impacted Maxillary Canine Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 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.

ORTHODONTICS

Background Surgical Technique Apically Positioned Flap Closed Eruption Technique

Surgical Technique Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2004 Sep;126(3):278-83 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

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

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):278-83.

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

Research Background Previous Studies Apically Positioned Flap VS Closed Eruption

Apically Positioned Graft 1977 Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod. 1977 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

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

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

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):9-14. 21 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. 2003 Dec;25(6):579-84. 12 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

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. 1977 Jul;72(1):53-64 - APG procedure in uncovering impacted teeth helps prevent marginal bone loss and gingival recession

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

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

RESULTS

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 1.000 0.800 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 0.600 Index Score 0.400 0.200 0.000 PI GI Treated 0.750 0.426 Contralateral 0.662 0.309 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

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 10.000 8.000 6.000 4.000 2.000 0.000 PD AG CCL Treated 1.868 4.159 9.141 Contralateral 1.765 3.735 9.012 Periodontal Parameter Comparison between treated and contralateral teeth PD: Probing Depth AG: Attached Gingiva CCL: Clinial Crown Length

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 100.000 2.500 95.000 2.000 % 90.000 85.000 mm 1.500 1.000 80.000 LOWER 95% CI MEAN UPPER 95% CI Treated 89.417 92.405 95.392 Contralateral 91.204 94.147 97.089 0.500 0.000 LOWER 95% CI MEAN UPPER 95% CI Treated 0.957 1.363 1.764 Contralateral 0.703 1.080 1.457 Treated Contralateral Difference Parametric variables Bony support (%) Bone level (CEJ~alveolar crest) 92.40 (1.371) * 1.36 (0.185) ** 94.14 (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

A.C. Caucasian Initial Records: 2003. 8 Age: 12Y5M Pictures by Courtesy of Dr. Pershing University of Pennsylvania

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

R.C. Caucasian Initial Records: 2004. 11 Age: 18Y Pictures by Courtesy of Dr. Degroote University of Pennsylvania

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

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

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

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

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