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Palatally impacted canines: The case for closed surgical exposure and immediate orthodontic traction
Adrian Beckera and Stella Chaushub Jerusalem, Israel

ur eminent discussants, Drs Mathews and Kokich, have provided a general overview of the problems associated with the surgical and orthodontic modality of the treatment of impacted maxillary canines, together with the available interceptive options. There is very little there with which one might take issue, but 1 point does require modication. Root resorption of the adjacent lateral incisor is not an aftermath of properly conducted treatment. Rather, it is a condition, which, with the benet of cone-beam technology, has been shown to affect two thirds of the patients seen in our clinics, before treatment is initiated.1 It is a progressive phenomenon and ceases only when the canine becomes distanced from its intimate contact with the incisor root.2-4 Alternatively, it might be the sequel to improper directional orthodontic traction that drives the canine directly against the incisor root. But this is faulty technique and, thus, irrelevant to the present discussion, in which we must assume the best treatment performance.
OPTIONS FOR TREATING PALATALLY IMPACTED CANINES

The interceptive methods of treating impacted canines are well known but are not at issue in this debate. In the ideal approach to the closed exposure strategy, as we see it, the orthodontist is present and will have tied-in a custom-designed traction spring during the few minutes between administration of the local anesthetic and its becoming effective.5 Once the tooth is exposed, an attachment is bonded to it, and, after full replacement of the surgical ap, active traction is applied. The patient
Clinical associate professor emeritus, Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. b Associate professor and chair, Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. Reprint requests to: Adrian Becker, Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, PO Box 12272, Jerusalem 91120, Israel; e-mail, adrian.becker@mail.huji.ac.il. Am J Orthod Dentofacial Orthop 2013;143:450-9 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.02.012
a

can then be seen a month or so later before further activation is needed. Quoting from their earlier study in their description of the open exposure technique, our discussants noted that autonomous eruption occurs within 6 to 9 months postoperatively, although there is apparently no report in the literature to support this statement.6 Their study describes the results from 49 consecutive patients who had at least 1 previous palatally impacted canine that had been exposed and allowed to erupt into the palate. They did not say in how many patients eruption had not occurred, how many teeth were deemed intractable and were extracted, and how many patients were found to be unsuitable for this method and referred for other treatment. There can be no argument that exposure of some impacted canines alone leads to autonomous eruption in time. However, no study has been initiated to discover which canines will respond in this way and which will fail, nor the speed with which eruption will occur in the successful cases. Failure will inevitably mean renewed surgery for our young patient. Success will usually have been the result of more radical surgery and exposure of the tooth, up to or beyond the cementoenamel junction; although the periodontium might be healthy in the long term, the labial aspect of the clinical crown will most likely be longer, with exposure of the cementum on the lingual side. This is not the experience that we have seen with the closed technique.
DISADVANTAGES OF UNCOVERING AND EARLY TRACTION

Resorption because of a canine crown (being) moved into close contact with the root of the adjacent lateral incisor can only occur (in either technique) if the direction of traction has not been properly determined or appropriately executed. This represents faulty treatment technique and, as such, is irrelevant to this discussion. Neither are the 2 literature references quoted in support of that assertion appropriate, since the authors had examined pretreatment records only.7,8

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We have no comment in regard to the fact that impacted teeth in adults tend to respond much later than do those in children or to the explanations given for this. However, since we have experienced failure of teeth to erupt despite the application of traction in patients in their fourth and fth decades of life, we have advised placement of a temporary anchorage device in the palate at the time of closed exposure and the immediate application of elastic traction for several months, until positive signs of movement are seen. Only then do we place orthodontic appliances on the other teeth and reevaluate our treatment options in light of the outcome.9
BENEFITS OF PREORTHODONTIC UNCOVERING AND AUTONOMOUS ERUPTION

Does the preorthodontic uncovering and autonomous eruption method reduce treatment time? Schmidt and Kokich6 reported an average treatment time of 33 months, with the preorthodontic proTHE SURGICAL We believe that creating space cedure taking a further 6 to PROCEDURE orthodontically before a minimal 9 months, for approximately The following is a descrip40 months in all. Yet, in the surgical exposure, bonding a small tion of our updated version of literature, we nd results attachment (an eyelet), full-ap the closed eruption techfrom immediate traction nique. closure, and immediate traction is methods producing treatment a safe and predictable option for 1. Leveling and alignment times of 25.8 and 32.3 of the teeth in the maxmonths for unilateral and bi- treating palatally impacted maxillary illa, followed by creating lateral cases, respectively10; canines in adolescents and adults. 26.3 months11; 19.7 the space in the canine months12; and 22 months.13 location. For adults, it has been reported that treatment takes 2. Accurately diagnosing the 3-dimensional location much longer14; that 30 more visits were required and orientation of the canine in space and in than for children15; and that 10 more visits were relation to the roots of the adjacent erupted teeth, required than for children, 9 of which directly related from suitable plane lm radiographs, although to the canine.12 cone-beam computerized tomography is strongly In the closed eruption technique, bone is left intact preferred.21 around the crown of the impacted tooth, even when it 3. Determining the direction that traction must be lies in the path of the intended direction of the applied to eliminate the impaction or entangleproposed traction. Experience derived from many ment with adjacent roots and designing an patients treated this way has shown that the teeth auxiliary spring,22 an auxiliary labial arch,23 a light palatal archwire,24 or an elastic traction hook, for respond rapidly to the applied force. There are indeed example, to achieve this. no cells capable of resorbing bone at the 4. Exposing the tooth (by the surgeon) with enamel-alveolar bone interface, but pressure a minimum of bone removal to reveal the follicle, demonstrably produces bone resorption and remodelwhich is opened at the most supercial point ing on the pressure side in exactly the same way as it only. Bone is not cleared away from the neck of does for every erupted tooth subjected to an orthodonthe tooth, nor is any attempt made to remove tic procedure that we perform in our ofces every more of the follicular tissue than is essential for day.16 The applied force causes hyalinization and undermining resorption, which quickly disappear due bonding, and certainly not down to the cementoto physiologic activity of scavenging cells in the enamel junction.5

immediate area. This has been demonstrated in relation to deeply embedded teeth that have been left for many months before traction is applied (when bone will have regenerated over the tooth), to cases of increased bone density (cleidocranial dysplasia), to canines associated with resorption of incisor roots (impossible to expose fully), and even to erupting an impacted tooth through an autogenous or synthetic bone graft.17 At the end of the process, there are no signs of pathology, and use of the term pathologic pressure necrosis is highly misleading, since it is part and parcel of the achievement of a successful outcome in all our orthodontic patients, whether they are routine or have an impaction.16 Furthermore, the references to our work have been misquoted,18,19 since closed surgery was reported there as showing marginally less bone support than an unaffected canine, but greater bone support than cases of open exposure.20

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5.

6.

7.

A small eyelet, threaded with soft twisted ligature wire of 0.012-in gauge, is then bonded (ideally by the orthodontist in attendance) while hemostasis is maintained (by the surgeon). The ap is then sutured fully back to its former place to cover the entire wound and exposed area, with the twisted ligature wire drawn through the ap at a point strategically placed to permit traction in the direction that will have been conrmed when the orthodontist actually sees the tooth in situ. The ligature is then immediately engaged by the spring mechanism before the patient leaves the surgeon's couch. The next activation would be made about a month later, when healing is well advanced and the tissues are not unduly sensitive.

It is probably true to say that canines whose impacted location is relatively supercial can benet from either method with little to distinguish between them, but equally it is true that some canines whose location and relationship to the roots of adjacent teeth make an open exposure out of the question. A canine that is associated with severe resorption of the root of the incisor cannot be exposed and left to erupt without seriously endangering the vitality and, often, the existence of the incisor, whereas a closed eruption technique can be the salvation of both teeth in a vital state.5 Palatal canines that are severely vertically displaced in the height of the maxilla, above the incisor apices, or those whose roots traverse the ridge to the labial side of the lateral incisor, cannot be treated by an open exposure technique; in contrast to treatment by a closed technique, these would be scheduled for extraction.25 They would then be eliminated from the study sample in a retrospective investigation of the periodontal condition of the outcome. The surgical ap is fully replaced at the end of treatment, thereby closing off the open wound to the oral environment. In this way, morbidity is lower than for open procedures, healing is faster, postoperative pain is considerably reduced, and postsurgical bleeding is virtually eliminated. In a series of quality-of-life studies performed in Jerusalem, we found that the after-pain, postsurgical discomfort, and loss of function were negative features that lasted approximately twice as long in patients after open surgery compared with those having closed surgical procedures.26-28 In several earlier studies in Jerusalem, in which the periodontal outcome of the treatment of impacted canines was reported, the patients who had the closed procedure showed signicantly better

results.18,19 Similar studies and outcomes have been reported elsewhere.20,29-34 These studies have been repeated for impacted maxillary central incisors, and again the results favored closed surgical exposure.35-37 There is no need for the placement of surgical packs that are not well tolerated and become unhygienic, even after 1 week in the mouth. The mere thought of leaving a pack in the mouth for 5 months would undermine the patient's quality of life. By making a minimal entry into the dental follicle and leaving the majority in place, the closed eruption technique leaves the cementoenamel junction area untouched. The normal gingival cuff will eventually be created with a junctional epithelial attachment on the cervical area of the crown of the tooth, directly on enamel. This is achieved through the ne layer of hemidesmosomes, cells that originate in the reduced enamel epithelium on the inner surface of the follicle, as the tooth breaks through the gingiva and during the follicle's metaplasia to become continuous with the gingival tissue. At the completion of treatment, the orthodontically erupted canine will appear as any newly erupted tooth, with a short clinical crown due to exuberant gingival tissue, which later retracts and makes the tooth clinically indistinguishable from any normally erupting tooth. We have noted above that the overall aims of treatment, by either method, include the ability to treat to the highest clinical standard. The ideal outcome demands that it be impossible to distinguish in the dental arch which was the previously impacted tooth, because its appearance, orientation, color, and gingival contour and height are identical with its antimere and in harmony with its neighbors. This is achievable in a high proportion of patients when the closed eruption technique is used in combination with properly executed directional orthodontic traction and alignment. For the preorthodontic open exposure method, only 19% of the previously impacted canines could escape detection by a panel of experts.6 One nal point relates to a pathologic condition that is uncommon, but familiar to endodontists, pediatric dentists, and dental traumatologists, although orthodontists seem to be entirely unaware of its existence. Invasive cervical root resorption is a condition seen after physical trauma, usually from a fall or a blow received by a child at school, or from chemical trauma from the leeching out of chemicals introduced into the occluded pulp chamber of root-treated teeth for bleaching. Impacted teeth are vital, but a radical exposure surgery taken down to the cementoenamel junction

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might denude the root surface and, with damage to the cementum layer, invasive cervical root resorption could begin at that site. Invasive cervical root resorption is a lesion, which, in its early stages, is difcult to diagnose on a radiograph, but, by the time the lesion has grown, bone is usually deposited in the depth of the resorption lacunae, and the tooth will no longer respond to extrusive traction.38 It is our view that this is the cause of many failed impacted teeth, rather than the knee-jerk and usually unproven application of the label ankylosis. Avoidance of extensive surgery down to the cementoenamel junction would appear to be called for, to reduce the likelihood of this possible sequel.
CONCLUSIONS

Our conclusions are identical to those of our respected discussants. We believe that creating space orthodontically before a minimal surgical exposure, bonding a small attachment (an eyelet), full-ap closure, and immediate traction is a safe and predictable option for treating palatally impacted maxillary canines in adolescents and adults. Our research and clinical experience show that this technique provides signicant benets to the orthodontist and the patient with a minimal risk of morbidity or failure of eruption.
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35. Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S. Closederuption surgical technique for impacted maxillary incisors: a postorthodontic periodontal evaluation. Am J Orthod Dentofacial Orthop 2002;122:9-14. 36. 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;25:579-84. 37. Chaushu S, Dykstein N, Ben-Bassat Y, Becker A. Periodontal status of impacted maxillary incisors uncovered by 2 different surgical techniques. J Oral Maxillofac Surg 2009;67:120-4. 38. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod 2013 Jan 23 [Epub ahead of print].

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