|Year : 2014 | Volume
| Issue : 3 | Page : 148-151
Guided tooth eruption: Comparison of open and closed eruption techniques in labially impacted maxillary canines
SM londhe1, Prasanna Kumar2, Sanjeev Datana1, Atul Kotwal2, Vivek Saxena3
1 Department of Orthodontics and Dentofacial Orthopedics, Army Dental Centre (R&R), New Delhi, India
2 Department of Orthodontics and Dentofacial Orthopedics, Armed Forces Medical College, Pune, Maharashtra, India
3 Command Military Dental Centre, Pune, Maharashtra, India
|Date of Web Publication||8-Dec-2014|
Department of Orthodontics and Dentofacial Orthopedics, Army Dental Centre (R&R), New Delhi
Source of Support: None, Conflict of Interest: None
Background: After third molars, the maxillary canines are the most commonly impacted permanent teeth and one-third of these are labial impactions. Impacted canines often require orthodontic guidance in the eruption. This study was conducted to assess the posttreatment results of surgically exposed and orthodontically aligned labially impacted maxillary canines comparing two different surgical techniques. Materials and Methods: The study was conducted in two phases, a surgical phase and an orthodontic phase. In surgical phase, events during surgical exposure and recovery of 31 patients with labially impacted maxillary canine were recorded. Patients were managed with open and closed eruption technique. The assessment included comparison of two techniques of surgical exposure, postoperative pain, mobility, vitality, periodontal health, level of impaction, and duration of orthodontic treatment. Results: The postoperative recovery was longer after open eruption than close eruption technique (P = 0.000). Postoperative pain experienced by patients was similar, but regression of pain was faster in closed eruption technique. The mean surgical time for open eruption technique was lesser when compared with closed eruption technique (P = 0.000). The total duration of orthodontic treatment was directly dependent upon the level of impaction, with deeper level of impaction having longer duration of orthodontic treatment. The mobility and vitality of guided canine was similar in both techniques. Conclusion: The closed eruption technique was a longer surgical procedure, but the postoperative pain regression was faster. The duration of orthodontic treatment was longer with deeper level of impaction. The closed eruption surgical techniques provide better periodontal tissues around the guided erupted teeth.
Keywords: Closed eruption technique, guided eruption, impacted maxillary canine, open eruption technique
|How to cite this article:|
londhe S M, Kumar P, Datana S, Kotwal A, Saxena V. Guided tooth eruption: Comparison of open and closed eruption techniques in labially impacted maxillary canines. J Dent Res Rev 2014;1:148-51
|How to cite this URL:|
londhe S M, Kumar P, Datana S, Kotwal A, Saxena V. Guided tooth eruption: Comparison of open and closed eruption techniques in labially impacted maxillary canines. J Dent Res Rev [serial online] 2014 [cited 2019 Mar 19];1:148-51. Available from: http://www.jdrr.org/text.asp?2014/1/3/148/146495
| Introduction|| |
The impaction of maxillary canine is a frequent clinical condition encountered in the orthodontic practice. The situation needs to be addressed with meticulous planning and a team approach. All possible efforts should be directed towards guiding the impacted tooth to the occlusion, as it forms the foundation of esthetic smile and functional occlusion. 
The fundamental principles considered for management of impacted canines includes: Surgical exposure, placement of attachment, and orthodontic guidance to the desired position. The primary goal of surgery is to provide adequate access for placement of an attachment and favorable tissue anatomy (good periodontal health).  Presently, two surgical approaches are employed for exposure of impacted maxillary canines; open eruption technique and closed eruption technique.
The objectives of the present study were to assess the posttreatment results of labially impacted maxillary canines managed with two different surgical exposure techniques and to compare final orthodontic alignment.
| Materials and Methods|| |
Patients requiring orthodontic eruption/guidance of labially impacted maxillary canines were selected for the present study over a span of 1 year. A written consent was obtained from all patients, and the study had an approval by the local ethical committee of the institution. Among the 31 patients taken up for guided tooth eruption, 12 (39%) were males and 19 (61%) females. The age profile of the patients was between 14 and 30 years (mean age 18 years). [Table 1] shows that 15 (48%), 13 (42%), and three (10%) patients had impacted tooth as maxillary left canine, maxillary right canine, and bilateral maxillary canine impaction, respectively. Orthodontic treatment was initiated for all patients to maintain/create adequate space for final position of the impacted canine.
The study was conducted in two phases, a surgical and an orthodontic phase. In surgical phase, two techniques (open and closed) for guided eruption were compared. Patients were selected at random (by lottery method) for the two techniques. Total duration of the surgical procedure, time period for full recovery and postoperative pain were assessed. In addition; age, gender, level of impaction, and the need for bone removal were recorded. Total duration of orthodontic treatment, periodontal condition, and vitality and mobility of the canines were assessed in the second phase of the study.
For the purpose of the study, a classification system for the impacted maxillary canine was advocated, wherein the distance of the impacted tooth was measured from the alveolar margin in an orthopantamograph (OPG). A distance of 1-5 mm from the alveolar margin was graded as Level I, 5-7 mm as Level II, and more than 7 mm as Level III [Table 2].
The surgery was performed according to the standard protocol followed in the tertiary care center. The same surgical team performed the two techniques on all the cases. In closed eruption technique, a mucoperiosteal flap was raised and an attachment (lingual button) was bonded to the exposed surface of impacted canine. A stainless steel ligature wire was tied on the attachment, which passed through or under the flap in the desired direction.The flap was sutured back to its former place. Light orthodontic traction was initiated immediately after the surgical procedure. , In open eruption technique no mucoperiosteal flap was raised. A surgical blade no. 12 was used to remove the fibrous mucosa covering the impacted tooth on the most prominent part of the impacted canine.  Rotatory instruments were used when needed.Attachment was bonded on the impacted tooth immediately after exposure. A light orthodontic traction was initiated with steel ligature tied on to the main archwire. Periodontal pack was used to prevent rehealing of the exposed part of the tooth. Moisture insensitive primer (MIP; 3M) was used in both techniques, to reduce the time period of attachment placement.
A visual analog scale was used to assess the degree of pain perceived by the patients after the surgical procedure and in follow-up period. Severe pain recorded as 8-10, moderate as 4-7, and mild as 1-3 on the analog scale.Follow-up recall was daily for first 7 days followed by monthly recall visits till the tooth had attained its predetermined position in the dental arch. The postoperative recovery period was recorded (time period required for pain perception to reduce to mild or no pain).
Radiovisiography (RVG) was doneat the end of treatment for all cases to check root resorption and continuity of lamina dura. Periodontal health of the erupted canines was assessed by measuring the pocket depth in all four sides of the guided tooth.
The statistical significance of the parameters was assessed using statistical tests of significance with P = 0.05.
| Results|| |
All the patients responded well on postsurgical exposure of the impacted canine. Out of 31 patients, one patient had transient neuropraxia ofinfraorbital nerve, which resolved over a period of 8 weeks. Four patients had edema involving the cheek on the operated side, while in 26 patients, there were no complications associated with the procedure.
The mean surgical time [Table 3] for open eruption technique was 22.31 ± 1.98 min as compared to 30.87 ± 2.38 min to closed eruption technique. The difference in time required for the two techniques was statically significant (P = 0.000).
Patients undergone closed eruption procedure experienced less pain with an average reading of 3.5 (±0.5) and patients with open eruption technique had an average reading of 3.75 (±0.75) and this was not statistically significant (P = 0.287).
The postoperative recovery was longer after open eruption than close eruption technique. The mean recovery period was 72 ± 4 and 48 ± 3.5 h for open and closed eruption techniques, respectively (P = 0.000). Postoperative pain experienced by patients was similar, but regression of pain was faster in closed eruption technique.
The total duration of orthodontic treatment depend upon the level of impaction. Patients who had level I impaction required guided eruption by orthodontic traction for an average period of 3 ± 1.3 months, patients with level II took an average of 5 ± 1.4 months, while Level III impactions required 7 ± 1.43 months in attaining their proper position in the dental arch. The mobility and vitality of guided canine was similar in both techniques, no statistically difference was noticed. On assessment of periodontal pocket depth, it was found that teeth which were treated with closed technique had better periodontal health [Table 4]. Distal aspect of the erupted canine showed increased periodontal breakdown.
Other parameters studied were amount of bone removed, swelling, and root structure; and no statistically significant differences were seen in comparison between the two groups.
| Discussion|| |
An impacted tooth can be defined as a tooth which has failed to erupt completely or partially to its correct position in the dental arch and has lost its eruption potential. After third molars, the maxillary canines are the most commonly impacted permanent teeth.  The incidences of maxillary canine impaction are 1-2.5%.  The need to retain or remove the impacted tooth is based on thorough clinical and radiological evaluation. And while a general consensus exists regarding removal of the impacted third molar tooth in either the maxilla or the mandible, an impacted canine tooth needs to be addressed in a different manner. Due to its vital importance in dentition, preservation of the tooth is the best alternative to maintain functional and esthetic integrity of the dental arch. ,
Guiding the tooth into occlusion requires a team approach. Surgical exposure of the impacted tooth involves placing a full thickness mucoperiosteal incision and exposing the tooth under local anesthesia. This may be carried out via an open or an alternative approach known as closed method.  The main advantages offered by closed technique include more conservative bone removal and rapid healing, whereas, the disadvantages include reexposure on failure of bonded attachment. The advantages of open technique include easy rebonding of attachment on bond failure, but the disadvantages include more bone exposure, risk of infection, and less healthy periodontal conditions .
Orthodontic correction of a malocclusion with an impacted maxillary canine takes longer than a similar malocclusion in which all the teeth are erupted. , Among the two surgical techniques studied, it was observed that the time required by closed technique was more as compared to open technique, this is in contrast with a study by Chaushu et al., and Pearson et al., , which concludedthat time required by closed technique was much lesser than open technique. In the present study MIP was used, thereby reducing the time required for bonding an attachment.
Distal surface of the erupted canine showed increase in periodontal pocket depth. This finding is in agreement with the findings of study conducted by Wisth et al., and Chaushu et al., The pain perception immediately after the two surgical techniques was similar, however, the postoperative recovery time was much less with closed eruption technique.
| Conclusion|| |
Conclusions made from the present study are:
- The surgical procedure was longer in closed technique as compared to open technique
- Postoperative pain experienced by patients was similar, but regression of pain was faster in closed eruption technique
- The recovery period with the closed technique was significantly less than the open technique
- The total duration of orthodontic treatment depends on the level of impaction, deeper the impaction longer the duration of treatment
- Canines managed with closed method had better periodontal health compared to canines managed with open method.
| References|| |
Londhe SM, Roy ID, Kumar P. Management of Bilateral impacted maxillary Canines. Med J Armed Forces India 2009;65:190-2.
Cercadillo-Ibarguren I, Gargallo-Albiol J, Abad-Sánchez D, Echeverría-García J, Berini-Aytés L, Gay-Escoda C. Periodontal health and esthetic results in impacted teeth exposed by apically positioned flap technique. Med Oral Patol Oral Cir Bucal 2011;16:e89-95.
McDonald F, Yap WL. The surgical exposure and application of direct traction of unerupted teeth. Am J Orthod 1986;89:331-40.
Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181-204.
Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop 2004;126:278-83.
Bass TB. Observation on the misplaced upper canine tooth. Dent Pract Dent Rec 1967;18:25-33.
Cooke J, Wang HL. Canine impactions: Incidence and management. Int J Periodontics Restorative Dent 2006;26:483-91.
Becker A. Palatally impacted canine. In: Becker A, editor. Orthodontic Treatment of impacted teeth 3 rd
ed. Hoboken: Wiley-Blackwell; 2012. p. 30-54.
Bishara SE. Impacted maxillary canines: A review. Am J Orthod Dentofacial Orthop 1992;101:159-71.
Stewart JA, Heo G, Glover KE, Williamson PC, Lam EW, Major PW. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop 2001;119:216-25.
Chaushu S, Becker A, Zeltser R, Branski S, Vasker N, Chaushu G. patients' perception of recovery after exposure of impacted teeth: A Comparison of closed-versus open-eruption techniques. J Oral Maxillofac Surg 2005;63:323-9.
Iramaneerat S, Cunningham SJ, Horrocks EN. The effect of two alternative methods of canine exposure upon subsequent duration of orthodontic treatment. Int J Paediatr Dent 1998;8:123-9.
Pearson MH, Robinson SN, Reed RT, Birnie DJ, Zaki GA. Management of palatally impacted canines: The findings of a collaborative study. Eur J Orthod 1997;19:511-5.
Wisth PJ, Norderval K, Boe OE. Periodontal status of orthodontically treated impacted maxillary canines. Angle Orthod 1976;46:69-76.
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.
[Table 1], [Table 2], [Table 3], [Table 4]