periodontal consideration in surgical exposure of impacted canine

1. PRESENTED BY:
DR. REBICCA RANJIT
IST YEAR RESIDENT
DEPT. OF PERIODONTICS
AN INTER-DEPARTMENTAL SEMINAR ON:
PERIODONTAL CONSIDERATIONS IN SURGICAL
EXPOSURE OF IMPACTED CANINES

2. The impacted canine has always implied a difficult
therapeutical management for the clinician.
The management of impacted canines demands a
“Multidisciplinary approach”

3. - The aim of orthodontic therapy is to guide tooth eruption to the
centre of the alveolar ridge
whereas,
periodontal–surgical management
must guarantee the respect of the gingival tissues to avoid
severe periodontal damage at the end of treatment.

4. Only if the forced eruption & the subsequent alignment
Brings tooth to a stable position in the dental arch along
with the presence of a HEALTHY PERIODONTIUM
When is the therapy of this condition
considered successful ???

5. a) Where forced eruption is not possible,
(E.g: Ankylotic-impacted tooth)
b) When, at the end of the alignment, the tooth presents
severe periodontal, functional & /or aesthetic problems
E.g:(Alveolar bone loss,
Reduced gingival tissue
or, at the worst,
Presence of a periodontal pocket or recession)
TREATMENT CONSIDERED UNSUCCESSFUL

6. - Eccentric eruption causes the irreversible destruction of the
gingiva that is ‘‘entrapped’’ between the erupting permanent
tooth & the corresponding deciduous tooth.
(Agudio et al. 1985, Pini Prato et al. 2000a, b)
- ‘‘If the tooth erupts in facial or lingual version, it may break
through the existing gingiva near the mucogingival junction’’
(Hall 1977).

7. BUCCALLLY PLACED CANINES
Absence of the attached gingiva
(Bowers 1963, Gormann 1967, Maynard & Ochsenbein 1975, Boyd 1978, Artun et al. 1986)
High incidence of gingival recessions
(Parfitt & Mjor 1964, Gormann 1967).

8. In the case of submucosal buccal impaction, where only the soft
tissue is involved, the keratinized gingiva must be preserved and
an apically positioned flap should be raised.
(Levin & D’Amico 1974, Vanarsdall & Corn 1977, Shiloah & Kopczyk 1978,
Boyd 1984).

9. In the case of deep intra-osseous impaction,
a more delicate management of the soft tissues & bone is
required to access the crown of the impacted tooth adequately
and to avoid subsequent severe periodontal damage.

10. WIDENING OF ATTACHED GINGIVA
ACCOMPLISHES FOLLOWING 3 OBJECTIVES:
 Enhances plaque removal around the gingival margin
 Improves esthetics
 Reduces inflammation around the treated tooth

11. Provides resistance to inflammation.
 Gives support to the marginal gingiva
Helps to withstand functional stress
Resistance to tensional stresses.
 Provides solid base for movable alveolar mucosa
Helps to prevent soft tissue recession & attachment loss
Helps in connective tissue attachment

12. SEQUELAE OF REDUCED WIDTH
OF ATTACHED GINGIVA

13. - Increased susceptibility to: infection
: masticatory force damage
- Decreased resistance to functional & tensional stresses.

14. Methods to appproach Buccally impacted Canine
 GINGIVECTOMY
 APICALLY REPOSITIONED FLAP
 CLOSED ERUPTION TECHNIQUE

15. GINGIVECTOMY / CIRCULAR
INCISION / OPEN
APPROACHA CIRCULAR Incision is made in the sulcus,
immediately over the crown, to expose the
bony crypt immediately beneath.

16.  Some authors have proposed performing a GINGIVECTOMY to
access the crown of the impacted tooth directly.
(Thilander et al. 1973, Archer 1975).
 Used only in limited situations:-
- Impaction above Mucogingival junction
- Presence of wide zone of Keratinized Gingiva

17. Some surgical problems such as
- Bleeding,
- Difficulty in the placement of the attaching device
- If the localization is not precise
Excessive removal of bone & soft tissues
Disadvantages:-

18. - Subsequent periodontal concerns, including
:- Recession
(Di Biase1971,Vanarsdall & Corn 1977,Odenrick & Modeer 1978, Boyd
1984,Tegsjo et al. 1984)
:- Bone loss
(Vanarsdall & Corn 1977),
:- Decreased width of keratinized tissue
(Kohavi et al. 1984a, Tegsjo et al. 1984),
:- Delayed periodontal healing
(Becker et al. 1996)

19. Apically Repositioned Flap
(Vanarsdall & Corn 1977)
- Procedure of Choice for soft tissue management
- Requires precise flap stabilization & Positioning.

21. Advantages
 Minimal exposure of the impacted tooth,
 Reduces surgical bleeding
 Facilitates the placement of the attaching device.
 Marked improvements in bonding materials eliminates the risk
of accidental loss of the attaching device during orthodontic
traction.
 Some authors reported OPTIMAL healing process (Chaushu et
al. 2004a,b) & final periodontal status (Tegsjo et al. 1984)

22. Disadvantages
-Unesthetic sequalae:-
-Increased Clinical crown length
-Gingival scarring
-Intrusive Relapse

23. Circumferential Supracrestal Fibrotomy’.
 Method to reduce of relapse.
 Periodontal fiber bundles that influence stability are:-
The principal fibers of PDL and The supra alveolar fibers.
 When performed in healthy tissues after orthodontics, there is
minimal attachment loss.

24. CLOSED ERUPTION TECHNIQUE /
FULL FLAP CLOSURE ( Mc Bride, 1979)
Best method to uncover Labially positioned canines
(Caprioglio et al , Quirynen et al 2000 )

25. Advantages
a) Maintains the width of the attached gingiva
b) No gingival scarring & good periodontal attachment is
established
c) No vertical relapse
d) Conservative bone removal
Disadvantages
a) Placement of the bonding attachment is necessary at the time of
exposure
b) Difficulty in gaining dry field

26. PALATALLY PLACED CANINES
 INTRA-ALVEOLAR-VERTICALLY POSITIONED CANINE
 FULL FLAP REFLECTION
 SUB-MARGINAL SEMILUNAR / TRAPEZOIDAL FLAP
 TUNNEL APPROACH

27. In Palatally Impacted Cases
Raise palatal flap
Eyelet attachment bonded in palatal side of the tooth
In these cases, a part of flap is removed for visual contact with
exterior

28. INTRA-ALVEOLAR-VERTICALLY POSITIONED
CANINE
- Buccal / Palatal exposure requires excessive amount of bone
removal
- Therefore, Crestal incision is given

29. Initial Occlusal view
Crestal incision given on the edentulous ridge
Buccal & Palatal flap raised
Bracket placed & area sutured
Result after completion

30. Full Thickness Flap Reflection
- Full thickness Flap reflection & its subsequent partial
replacement over the exposed tooth along with placement of
Surgical pack.
(Lappin,1951;Johnston,1969; Lewis ,1971; Von der Heydt;1975)

31. PROCEDURE

33. Advantages
:- Provision of access,
:- Enables direct traction
Disadvantages
:- Requires planned sacrifice of mush of bone,
:- Unacceptably reduced bone support ,
:- Poorer Periodontal prognosis.

34. SUB-MARGINAL SEMILUNAR/TRAPEZOIDAL
FLAP
Smukler & Colleagues,1987

36. Not Only the Technique We use determine the prognosis of the
treated tooth.. but also the direction of Orthodontic traction

37. Palatally impacted canines are guided to
occlusion in 2 STEPS:-
Ist Guide tooth to oral enviroment
Then Guide tooth to line of arch

38. If SS pigtail ligature is drawn with direct traction towards the
line of arch
Tooth is drawn bucally & vertically downward
Draws the tooth laterally against alveolus & its healing
granulation tissue
Exposed tooth will become reburied in these tissues
Inflammation & false Pocketing
Acute Lateral abscess

39. Direct Traction Vs 2-Staged Traction

40. In case of an intra-osseous-impacted
canine associated with the persistence
of the correspondent deciduous tooth in
the dental arch.
OVER RETAINED DECIDUOUS CANINE

41. Tunnel Approach (Crescini et al,1994)
 The extraction of the deciduous tooth provides a natural
osseous tunnel. Traction through this tunnel follows an
eruption path that closely simulates the physiological
one.

42. Full Flap reflected
Impacted tooth exposed;leaving the buccal plate inferior to it intact
Deciduous canine extracted
Socket extended & widened sufficiently
A tunnel in bone is provided by the vacated socket of simultaneously extracted deciduous
canine
Fine wire passed through it reaching upto impacted tooth
SS pigtail ligature is drawn from bonded eyelet attachment inferiorly to emerge from occlusal
end of Deciduous canine socket
Surgical flap resutured to its former place

43. Preservation of bucccal plate
inferior to impacted Canine
The stainless steel pigtail is drawn inferiorly through
the vacated socket of the deciduous canine.

44. 1 year after completion of treatment
Note:-the gingival height, wide attached
gingiva & good bony contour
At 2.5 months post surgery

45. TUNNEL APPROACH

46. Advantages:-
- Good access to Canine
- Preserves buccal plate of Bone
- Treatment result shows good bony profile & uncompromised periodontal
result.
- No attachment & Bone loss
- Minor degree of difficulty in threading the ligature.
Disadvantages:-

47. Advocates of the closed eruption approach note benefits:
• A possibility to influence the direction of the extrusion of the
impacted tooth
• Patient comfort during the healing process
(Chaushu et al., 2005; Gharaibeh and Al-Nimri, 2008)
• Reduced surgical bleeding,
• Easier placement of the attaching device
(Becker et al. 1996),
• Aceptable periodontal health after treatment
(Quirynen et al., 2000;Crescini et al.,2007a,b; Zasciurinskiene et al., 2008).

48. The clinicians who support open exposure technique and
spontaneous eruption of the canine claim potential
advantages:
 The ability to observe the impacted tooth movement during
treatment
 no need of attachment bonding at the time of surgery
 Time saving during surgical procedure
(Pearson et al., 1997; Gharaibeh and Al-Nimri, 2008)

49. The periodontal status of impacted
canines following surgical orthodontic
treatments has been investigated in the
past…

50. - Heaney & Atherton 1976
- Wisth et al. 1976
- Odenrick & Modeer 1978
- Boyd 1982, 1984
- Becker et al. 1983
- Kohavi et al. 1984a, b
- Tegsjo et al. 1984,
- Crescini et al. 1994, 2007a, b
- Hansson & Rindler 1998
- Quirynen et al. (2000)

51. Most of these Short-term evaluations
Concluded :
 Greater Pocket Depth, Attachment Loss & Distance from CEJ to
Interdental bone in experimental tooth than in contra-lateral tooth.
(Wisth et al. 1976, Hansson & Rindler 1998, Szarmach et al. 2006, Becker et al.
1983, Schmidt & Kokich,2007)
 The use of a closed-flap surgical technique allowed alignment of
palatally impacted canines without damage to the periodontium.
(Caprioglio et al)
 Increased Probing Depth, Keratinized thickness, Recession in
surgically erupted canines
(Crescini et al. 1994)

52. A long-term evaluation on a small sample size was
performed by Quirynen et al. (2000):
Used combined surgical (closed eruption technique ) &
careful orthodontic approach

53. This Retrospective study showed:-
 No significant differences in Bone support & recession in
between orthodontically extruded & spontaneously erupted
Canines.
 Orthodontically extruded impacted Canines showed lesser (1
mm) gingival width.
 With this one can conclude that, closed eruption technique
with conservative Periodontal surgery & careful
Orthodontics can give excellent long-term result.

54. - Mucogingival interceptive surgeries ,when used
judiciously & at appropriate time, can be helpful in
preventing future mucogingival problems.
- This requires a co-ordinated approach on the part of
Periodontist- surgeon- orthodontist, which would
ultimately benefit the patient in maintaining a trouble-free
Periodontium.

55. REFERENCES:-

56.  The orthodontic treatment of impacted teeth, Adrian Becker, 3rd Edition
 Atlas of Cosmetic and Reconstructive Periodontal Surgery, Edward S.
Cohen, 3rd Edition
 Hansson C.,Rindler A. :Periodontal conditions following sugical &
orthodontic treatment of Palatally Impacted Maxillary Canines-a
follow-up Study. Angle Orthod 1998 Apr;68(2):167-72
 Crescini A, Nieri M, Buti J, Baccetti T, Mauro S, Pini Prato GP:Short-
and long-term periodontal evaluation of impacted canines treated with a
closed surgical–orthodontic approach.
J Clin Periodontol 2007; 34: 232–242.

57.  Artun J, Osterberg SK and Joondeph DR: Long-term periodontal
status of labially erupted canines following orthodontic treatment. J
Clin Periodontol 1986:13:856—861.
 R. Vijayalakshmi, T. Ramakrishnan, S. Nisanth :Surgical exposure of
an impacted maxillary canine and increasing a band of keratinized
gingiva.
Journal of Indian Society of Periodontology – 13(3)Sep-Dec 2009.
 Caprioglio A. , Vanni A. and Bolamperti L. Long-term periodontal
response to orthodontic treatment of palatally impacted maxillary
canines.
European Journal of Orthodontics 35 (2013) 323–328
 Wisth et al. : Periodontal Status of Orthodontically treated Impacted
Maxillary Canine.
Angle Orthod 1976; 46: 69–76

58.  Becker A, Chaushu S Success rate & duration of orthodontic treatment
for adult patients with palatally impacted maxillary canines.
Am Journal of Orthodontics & Dentofacial Orthopedics 2003 ;124: e509–e514
 L. Odenrick,T. Modeer: Periodontal status following surgical-
orthodontic alignment of impacted teeth;
Acta Odontologica Scandinavica, 1978, Vol. 36, No. 4 : Pages 233-236
 Boyd R. L. (1978) Mucogingival considerations and their relationship
to orthodontics. Journal of Periodontology 49, 67–76.
 Caprioglio A.,Vanni A.,Bolamperti L.: Long-term periodontal response
to orthodontic treatment of palatally impacted maxillary canines.;
Eur J Orthod 2013 Jun;35(3):323-8

59.  Quirynen M.,Op Heij DG, Adriansens A, Opdebeeck HM,
Periodontal health of orthodontically extruded impacted teeth. A
split-mouth, long-term clinical evaluation;
J Clin Periodontol 2000 Nov;71(11):1708-14