SYSTEMATIC REVIEW

Periodontal status after surgical-orthodontic

treatment of labially impacted canines with
different surgical techniques: A systematic review
Serena Incerti-Parenti,a Vittorio Checchi,b Daniela Rita Ippolito,c Antonio Gracco,d and Giulio Alessandri-Bonettie
Bologna, Trieste, Brescia, and Padua, Italy

Introduction: Good periodontal status is essential for a successful treatment outcome of impacted maxillary canines. Whereas the surgical technique used for tooth uncovering has been shown not to affect the nal periodontal status of palatally impacted canines, its effect on labially impacted canines is still unclear. Methods:
Searches of electronic databases through January 2015 and reference lists of relevant publications were
used to identify studies evaluating the periodontal status of labially impacted canines after combined surgicalorthodontic treatment. Two reviewers independently screened the articles, extracted data, and ascertained
the quality of the studies. Results: Ninety-one studies were identied; 3 were included in the review. No included
study examined the periodontal outcome of the closed eruption technique. Excisional uncovering was reported
to have a detrimental effect on the periodontium (bleeding of the gingival margin, 29% vs 7% in the control group;
gingival recession,
0.5 mm [SD, 1.0] vs
1.5 mm [SD, 0.8] in the control group; and width of keratinized gingiva,
2.6 mm [SD, 1.4] vs 4.1 mm [SD, 1.5] in the control group). Impacted canines uncovered with an apically positioned ap had periodontal outcomes comparable with those of untreated teeth. Conclusions: The current literature is insufcient to determine which surgical procedure is better for periodontal health for uncovering labially
impacted canines. (Am J Orthod Dentofacial Orthop 2016;149:463-72)

axillary canine impaction is a clinical condition

commonly encountered in dentistry. Approximately 2% of the general population and 4%
of the subjects referred to orthodontists are affected,1,2
with a third of the impacted maxillary canines located
labially.3
Arch length deciency has been reported to play an
important role in the etiology of labial impactions:
Jacoby4 found that only 17% of labially impacted canines had sufcient space to erupt. Orthodontic
a
PhD student, Unit of Orthodontics, Department of Biomedical and Neuromotor
Sciences, University of Bologna, Bologna, Italy.
b
Researcher, Department of Medical Sciences, University of Trieste, Trieste, Italy.
c
Postgraduate student, Department of Orthodontics, School of Dentistry, University of Brescia, Brescia, Italy.
d
Assistant professor, Department of Neuroscience, University of Padua, Padua,
Italy.
e
Associate professor, Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Giulio Alessandri-Bonetti, Unit of Orthodontics,
Department of Biomedical and Neuromotor Sciences, University of Bologna,
Via San Vitale 59, Bologna 40125, Italy; e-mail, giulio.alessandri@unibo.it.
Submitted, February 2015; revised and accepted, October 2015.
0889-5406/$36.00
Copyright 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.10.019

mechanics to open the space for the canine crown might

lead to spontaneous eruption, but when space has been
created and the canine does not erupt within a reasonable time, surgical uncovering of the impacted tooth
should be considered. Three techniques are generally
used to uncover labially impacted canines: excisional
uncovering (gingivectomy), apically positioned ap,
and closed eruption.5
One fundamental indicator of a successful outcome
in the treatment of impacted canines is the nal periodontal status.6 A recent randomized clinical trial by
Parkin et al7 showed that exposure and alignment of
palatally impacted maxillary canines has a small periodontal impact that is unlikely to be clinically relevant,
without signicant differences in periodontal health between the open and closed techniques. Labial impactions seem to be more challenging to manage without
adverse periodontal problems, and the surgical technique used to uncover the canine is thought to be critical
for the nal periodontal health because it affects the
amount of attached gingiva over the tooth crown after
eruption.8 However, the actual periodontal impact of
the surgical technique used to uncover labially impacted
canines is still unclear; to date, no systematic review has
been undertaken on this topic.
463

Incerti-Parenti et al

464

The purpose of this study was to systematically review the literature on the periodontal status of labially
impacted canines after combined surgical-orthodontic
treatment with different surgical approaches to clarify
whether there is sufcient evidence to support one surgical technique over the others in terms of periodontal
health.

5.
6.

7.

MATERIAL AND METHODS

Eligibility was assessed on the basis of the following

inclusion criteria.
 The population was patients receiving surgical treatment to correct labially impacted maxillary canines.
No restriction for age, malocclusion, or type of orthodontic treatment was applied. Studies including both
labial and palatal impactions were excluded because
of the anatomic differences in the keratinized tissues
between the palatal and labial mucosae. Studies
including both incisors and canines were excluded
because of the differences in the etiology of their impactions.
 The intervention was combined surgical-orthodontic
treatment of labially impacted canines. At least 1 of
the following surgical techniques had to be used in
the study: closed surgical technique, excisional uncovering (radical exposure), or apically positioned
ap.
 For comparison, when 1 technique was considered,
the untreated contralateral side had to be used as
the control. When 2 surgical techniques were
compared, no untreated control group was required.
 Outcomes; studies were considered for inclusion if at
least 1 of the following parameters was evaluated.
1.

2.

3.

4.

Plaque accumulation: plaque volume on the

dental surfaces. The Plaque Index by Silness
and Loe,9 scored with a 4-point scale (0-3), is
widely used to assess plaque accumulation.
Gingival inammation: assessment of the inammatory conditions of the gingiva can be
based on visual inspection and bleeding of the
gingival margin (Gingival Index)10 or on gingival
bleeding tendency alone (Gingival Bleeding Index)11 or bleeding tendency.12
Recession: distance from the cementoenamel
junction (CEJ) to the gingival margin, with the
gingival margin apical to the CEJ being positive,
and the gingival margin coronal to the CEJ being
negative.
Periodontal probing depth: distance from the
gingival margin to the location of the tip of a
periodontal probe inserted into the pocket.

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8.

Clinical attachment level: distance from the CEJ

to the location of the inserted probe tip.
Width of the keratinized gingiva: distance between the most apical point of the gingival
margin and the mucogingival junction.
Width of the attached gingiva: distance between
the mucogingival junction and the projection on
the external surface of the bottom of the gingival
sulcus. It is obtained by subtracting the periodontal probing depth from the width of the keratinized gingiva.
Crestal bone loss: distance between the CEJ and
the alveolar bone crest measured on intraoral radiographs.

 Study designs: randomized controlled trials,

controlled clinical trials, and observational studies
(cohort and case-control studies) were considered for
inclusion if they fullled the population, intervention,
comparisons, and outcomes criteria detailed above.
Information sources, search strategy, and study
selection

The following databases were searched from their

inception to January 2015 for relevant studies: PubMed,
Cochrane Central Register of Controlled Trials, LILACS,
and Scopus. There were no language restrictions. To identify the relevant studies the following search strategy was
used: Search ((impact* OR unerupt* OR ectopic*) AND
(labial* OR buccal* OR vestibular*) AND ((maxilla* OR upper) AND (canine* OR cuspid*)) AND (surgery or surgical*)); lters: humans. Further studies were identied by
hand searching the reference lists of all relevant articles.
The rst step in the screening process was to unduplicate the references by importing them into the reference management software Mendeley (http://www.
mendeley.com/features/reference-manager/). Two authors (D.R.I., S.I-P.) independently screened titles and
abstracts. For studies that appeared to be relevant, or
when a denite decision could not be made based on
the title or abstract alone, the full article was obtained
and independently examined by the reviewers for
detailed assessment against the inclusion criteria.
Because of the dichotomous nature of the ratings
(accept or reject), agreement between the assessors (interassessor reliability) was formally assessed using the
kappa statistic. Disagreements were resolved by discussion. When resolution was not possible, a third reviewer
(G.A-B.) was consulted.
Data items and collection

Data extraction included the following items: (1) rst

author, year of publication, and location; (2) study

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Incerti-Parenti et al

design; (3) population characteristics (subjects enrolled,

mean age, and sex distribution); (4) intervention (surgical exposure, orthodontic traction); (5) investigated
comparisons; (6) follow-up of the study; (7) outcome
measures; (8) signicance level of the statistical tests;
and (9) outcomes.
Two authors (D.R.I., S.I-P.) independently performed
the data extraction using a previously piloted form. Disagreements were resolved by discussion. When resolution was not possible, a third reviewer (G.A-B.) was
consulted.
Quality assessment in the studies

Two authors (V.C., A.G.) were blinded to the authors

and the sources of each reference and independently assessed the research design as well as a 3-category rating
of the internal validity of each study (according to
criteria that varied depending on the study design), as
stated by the U.S. Preventive Services Task Force
(Table I).13 Disagreements were resolved through
consensus. The Spearman rank correlation coefcient
was applied to evaluate the agreement between the
raters.
Data synthesis

The ndings of the studies included in the systematic

review were gathered. A quantitative synthesis using
formal statistical techniques such as meta-analysis
seemed inappropriate because the selected studies
were too few, with nonrandomized designs and a lack
of homogeneity in the study settings. Therefore, a narrative synthesis was carried out.
RESULTS
Study selection and characteristics

The Figure shows the ow of the literature search according to the PRISMA format.14 The comprehensive
search yielded 91 potentially relevant studies. Screening
excluded 77 publications based on titles and abstracts.
The full-text analysis of the remaining 14 studies led
to the exclusion of 11 more articles (Table II).6,15-24
Therefore, 3 studies fully met the eligibility criteria and
were included in the review (Tables III and IV ).25-27
Excellent agreement between reviewers was found
both in the screening (titles and abstracts, k 5 0.917;
full texts, k 5 1.000) and in the quality assessment
(Table V; P 5 1.000).
Results of individual studies

The authors of 1 prospective study evaluated the effects on the periodontal tissues of 2 surgical approaches:

465

Table I. US Preventive Services Task Force rating of

study quality
Denition of ratings
Study design
I
Properly randomized controlled trial
II-1
Well-designed controlled trial without randomization
II-2
Well-designed cohort or case-control analytic study,
preferably from more than 1 center or research
group
II-3
Multiple time series with or without the intervention;
dramatic results in uncontrolled experiments could
also be regarded as this type of evidence
III
Opinions of respected authorities, based on clinical
experience, descriptive studies, and case reports, or
reports of expert committees
Internal validity*
Good
The study meets all criteria for that study designy
Fair
The study does not meet all criteria for that study
design but is judged to have no fatal aw that
invalidates its resultsy
Poor
The study contains a fatal aw
Derived from Harris et al.13
*Internal validity is the degree to which the study provides valid evidence for the population and setting in which it was conducted;
y
criteria for grading internal validity (limited to the study designs
of the studies included in the review) were reported in Table V.

radical exposure (entire labial aspect of the crown

exposed) and partial exposure (2-3 mm of keratinized
tissue maintained with either an apically positioned
ap or a tissue excision).25 Twenty-four patients with
a unilateral labially impacted maxillary canine treated
with surgical exposure and orthodontic alignment
were enrolled; 12 had radical exposure, and 12 had partial exposure. Periodontal status (including plaque accumulation, gingival inammation, gingival recession, loss
of attachment, and width of attached gingiva) was evaluated 6 to 24 months after removal of the xed appliances. The radical exposure group appeared to have
more gingival inammation, gingival recession, and
loss of attachment than both the contralateral untreated
canine and partial exposure groups. However, only the
values of the width of the attached gingiva were reported
in the article; the other data were provided solely as boxand-whisker plots (without medians indicated)
(Table IV). Therefore, it was not possible to accurately
present in the review the extent of the detrimental effect
of radical exposure when compared with untreated
canines.
Kim et al27 evaluated the periodontal health of 23
labially displaced canines, exposed with an apically positioned ap technique. Periodontal outcomes, evaluated
at least 1 year after the surgery, were compared with
those of the contralateral untreated canines. Canines
exposed with an apically positioned ap, when

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466

Fig. Flow diagram (in PRISMA format) of the literature search.

Table II. Excluded studies with reasons

Authors, year
Caminiti et al,15 1998
Crescini et al,16 1994
Crescini et al,6 2007
Gaulis and Joho,17 1978

Odenrick and Mod
eer,18

1978

O'Dowling,19 2009
Quirynen et al,20 2000
Soroka-Letkiewicz et al,21
2005
Szarmach et al,22 2006
Vermette et al,23 1995
Wisth et al,24 1976

Reason for exclusion

Unsuitable sample (palatal and labial
impactions)
Unsuitable sample (palatal and labial
impactions)
Unsuitable sample (palatal and labial
impactions)
Unsuitable sample (palatal and labial
impactions), inadequate
methodology (no inferential
statistics)
Unsuitable sample (incisors and
canines, palatal and labial
impactions), inadequate
methodology (no inferential
statistics)
Review outcomes of interest not
reported in the study
Unsuitable sample (palatal and labial
impactions)
Unsuitable sample (incisors and
canines), inadequate methodology
(no inferential statistics)
Unsuitable sample (palatal and labial
impactions)
Unsuitable sample (incisors and
canines)
Unsuitable sample (palatal and labial
impactions)

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compared with untreated canines, showed no signicantly different values in the Plaque Index, Gingival Index, probing depth, width of attached gingiva, clinical
crown length, and crestal bone loss (Table IV).
Only 1 study directly compared excisional uncovering
and the apically positioned ap technique.26 Twentyone participants received a radical exposure, and 29 patients had an apically positioned ap. The untreated
contralateral canines served as controls. The apically
positioned ap group, when compared with the control
group, showed no signicant differences in Gingival
Bleeding Index, width of keratinized gingiva, periodontal probing depth, and recession. Conversely,
most of the periodontal indexes after excisional uncovering were less favorable than those in untreated canines
(Table IV).
DISCUSSION
Summary of evidence

Excisional uncovering of impacted canines was reported to have a detrimental effect on the periodontium:
uncovered canines, when compared with the contralateral untreated teeth, had signicantly more gingival
inammation (Gingival Bleeding Index, buccal: radical
exposure, 29%; control, 7%), gingival recession (radical
exposure: mean,
0.5; SD, 1.0 mm; and control: mean,

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467

Table III. Characteristics of included studies

Characteristics
Participants
Inclusion criteria

Subjects, n (% male)
Mean age (y) (SD, range)
Intervention

Boyd,25 1984

Tegsjo et al,26 1984

Kim et al,27 2007

Unilateral labially impacted

maxillary canine
Surgical exposure and orthodontic
alignment of the impacted
canine
All appliances removed for a
minimum of 6 months
24 (33%)
- (-, 15/22) at time of the study

Unilateral labially impacted

maxillary canine
Surgical exposure of the impacted
canine performed between
1977 and 1979

Labially impacted maxillary canine

RE: entire crown exposed by the

window approach

Outcomes

GBI, WKT (lab), PPD, REC

Study design

Controlled clinical trial

Retrospective cohort study

Comparisons

Recall period (mo)

Minimum recall period of 1 year

after the surgery
20 (-)
-

50 (44%)
12.9 (-, 10/18) at time of the
surgery
RE: surgical uncovering; surgical
dressing for 1 week;
orthodontic traction

PE: 2-3 mm of keratinized tissue

maintained with either an APF
or a tissue excision
RE vs CTR
PE vs CTR
RE vs PE
6-24 after removal of xed
appliances
PI, GI, BT, REC, PPD, LA, WAG

Surgical exposure of the impacted

canine through APF

Full xed orthodontics; surgical

uncovering (APF); surgical
dressing for 1 week;
orthodontic traction

APF: Surgical uncovering; surgical

dressing for 1 week;
orthodontic traction
RE vs CTR
APF vs CTR
RE vs APF
30-56 after surgical exposure

APF vs CTR

Minimum of 12 after surgery

PI, GI, PPD, WAG, clinical crown
length, bone loss
Retrospective cohort study

RE, Radical exposure; PE, partial exposure; APF, apically positioned ap; CTR, control group; PI, Plaque Index; GI, Gingival Index; GBI, Gingival
Bleeding Index; BT, bleeding tendency; REC, recession; PPD, pocket probing depth; LA, loss of attachment; WAG, width of attached gingiva; WKT,
width of keratinized gingiva; lab, labial.

1.5; SD, 0.8 mm), and reduced width of keratinized

gingiva (radical exposure: mean, 2.6; SD, 1.4 mm; and
control: mean, 4.1; SD, 1.5 mm).25,26
For the closed eruption vs the control groups, none of
the included studies compared the periodontal outcomes between canines uncovered with the closed eruption technique and untreated canines. The excluded
studies on this topic had inconsistent results. Crescini
et al,6,16 using a closed surgical technique with tunnel
traction, at a 3-year follow-up found no signicant differences between the periodontal indexes of treated and
untreated canines, with a signicance level set at 0.05,
whereas Vermette et al23 detected in the closed eruption
group narrower attached gingiva on the distal surface
(closed surgical technique: mean, 3.5; SD, 1.49 mm;
and control: mean, 4.2; SD, 1.33 mm; P \0.03) and
crestal bone (probing bone level) located more apically
on the facial surface (closed surgical technique: mean,
2.1; SD, 0.79 mm; and control: mean, 1.6; SD,
0.51 mm; P \0.02). However, the ndings from these
studies were not conclusive because they included
both palatal and labial impactions6,16 or both incisors
and canines.23 Moreover, Crescini et al included only
unilateral deep infraosseous impactions, thus restricting

the external validity of their study. The differences found

by Vermette et al were small (\1 mm) and therefore unlikely to be clinically signicant.
For the apically positioned ap vs the control groups,
the periodontal statuses of the canines were not significantly different.26,27 Boyd25 failed to differentiate excisional uncovering from apically positioned ap (both
were included in the partial exposure group); therefore, no conclusion could be drawn regarding the periodontal status after the apically positioned ap
approach compared with untreated canines. Among
the excluded studies, Vermette et al,23 who analyzed
the distance from the gingival margin to the CEJ (with
negative recording indicating a gingival margin located
apically to the CEJ), found that teeth uncovered with an
apically positioned ap showed more apical gingival
margins on the mesial aspect (apically positioned ap:
mean, 2.1 mm; SD, 0.67 mm; and control: mean,
2.4 mm; SD, 0.61 mm; P \0.01) and the facial surfaces
(apically positioned ap: mean, 0.6 mm; SD, 1.04 mm;
and control: mean, 1.3 mm; SD, 0.69 mm; P \0.01).
Moreover, they found greater crown length on the midfacial surface (apically positioned ap: mean, 10.1 mm;
SD, 1.00 mm; and control: mean, 9.5 mm; SD, 0.98 mm;

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Table IV. Periodontal outcomes reported in the included studies

Boyd,25 1984

CTR

RE

PE

PI
GI

NR

NR

NR

BT

NR

NR

NR

Tegsjo et al,26 1984

Signicance
only
P \0.05

NR

NR

NR

RE . CTR
RE . PE

PPD
Buccal

Palatal

Distal

NR

NR

NR

Clinical
crown
length

NR

0.0 mm

3.67 mm
(SD, 1.72 mm)

7%

29%

7%

NR

CTR*
0.66 (SE, 0.143)
0.30 (SE, 0.108)

APF*
0.75 (SE, 0.150)
0.43 (SE, 0.120)

Signicance
only
P \0.05
NS
NS

RE . APF
RE . CTR
RE . CTR

1.5 mm
(SD, 0.8 mm)y

1.1 mm
(SD, 0.9 mm)z

0.5 mm
(SD, 1.0 mm)

0.9 mm
(SD, 1.2 mm)

1.6 mm
(SD, 0.6 mm)y
1.6 mm
(SD, 0.4 mm)z
1.9 mm
(SD, 0.6 mm)y
2.2 mm
(SD, 0.7 mm)z
1.9 mm
(SD, 0.5 mm)y
2.0 mm
(SD, 0.5 mm)z
2.0 mm
(SD, 0.6 mm)y
2.1 mm
(SD, 0.6 mm)z

1.2 mm
(SD, 0.4 mm)

1.4 mm
(SD, 0.4 mm)

APF . RE
CTR . RE

2.4 mm
(SD, 0.6 mm)

2.1 mm
(SD, 0.5 mm)

NS

2.1 mm
(SD, 0.5 mm)

2.0 mm
(SD, 0.5 mm)

NS

2.6
(SD, 0.6 mm)

2.2 mm
(SD, 0.6 mm)

NS

4.1 mm
(SD, 1.5 mm)y
3.9 mm
(SD, 1.5 mm)z

2.6
(SD, 1.4 mm)

4.3 mm
(SD, 1.8 mm)

APF . RE
CTR . RE

RE . CTR
RE . PE

WKG

WAG

APF

Signicance
only
P \0.01

1.76 mm
(SE, 0.092 mm)

1.86 mm
(SE, 0.105 mm)

NS

3.73 mm
(SE, 0.254 mm)
9.01 mm
(SE, 0.418 mm)

4.16 mm
(SE, 0.410 mm)
9.14 mm
(SE, 0.371 mm)

NS
NS

Incerti-Parenti et al

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Mesial

LA

RE

RE . CTR
RE . PE
RE . CTR
RE . PE

GBIb
REC

CTR

Kim et al,27 2007

469

Data are presented as means and standard deviations unless otherwise stated.
CTR, control group; RE, radical exposure; PE, partial exposure; APF, apically positioned ap; PI, Plaque Index; GI, Gingival Index; BT, bleeding tendency; GBIb, Gingival Bleeding Index (buccal); REC,
Recession; PPD, pocket probing depth; LA, loss of attachment; WKT, width of keratinized gingiva; WAG, width of attached gingiva; NR, not reported; NS, not signicant.
*Data are presented as means and standard errors; yRE control group; zAPF control group.

NS
1.36 mm
(SE, 0.185 mm)

APF*
CTR*
APF
RE
PE
RE
CTR

Bone loss

Table IV. Continued

Boyd,25 1984

Signicance
only
P \0.05

CTR

Tegsjo et al,26 1984

Signicance
only
P \0.01

1.08 mm
(SE, 0.173 mm)

Kim et al,27 2007

Signicance
only
P \0.05

Incerti-Parenti et al

P \0.02), increased probing attachment level on the

facial surface (apically positioned ap: mean,

1.4 mm; SD, 1.15 mm; and control: mean,

0.8 mm; SD, 0.62 mm; P \0.02), increased width of
attached gingiva on the facial surface (apically positioned ap: mean, 3.5 mm; SD, 2.08 mm; and control:
mean, 1.9 mm; SD, 0.68 mm; P \0.002), increased
probing bone level on the mesial aspect (apically positioned ap: mean, 2.3 mm; SD, 0.57 mm; and control:
mean, 1.8 mm; SD, 0.71 mm; P \0.007), the facial
aspect (apically positioned ap: mean, 2.4 mm; SD,
0.98 mm; and control: mean, 1.6 mm; SD, 0.61 mm;
P \0.002), and the distal aspect (apically positioned
ap: mean, 2.2 mm; SD, 0.62 mm; and control: mean,
1.7 mm; SD, 0.57 mm; P \0.007). As stated above,
the sample of Vermette et al consisted of both canines
and incisors, and the inadequate sample was the reason
for the exclusion of this study.
None of the included studies examined the differences in periodontal outcomes between canines uncovered through excisional uncovering and the closed
eruption technique. Among the excluded studies, Odenrick and Mod
eer18 detected a greater frequency of recessions (recession 5 gingival margin apical to the CEJ) in
teeth uncovered with excisional uncovering than in
those in which a closed eruption technique was used
(closed surgical: labial recession, 1/11; lingual recession,
0/11; and radical exposure: labial recessions, 4/11;
lingual recessions, 3/11). However, these ndings were
rather unreliable because of an inadequate sample
(including both incisors and canines, and palatal and
labial impactions), the chosen outcome measurements
(frequency of recession rather than its measurement in
millimeters), and no statistical analysis.
Excisional uncovering resulted in a worse periodontal
outcome than an apically positioned ap: gingival
inammation was more pronounced with the Gingival
Bleeding Index (radical exposure: 29%; apically positioned ap: 7%), and the width of keratinized gingiva
was more reduced (radical exposure: mean, 2.6 mm;
SD, 1.4; and apically positioned ap: mean, 4.3 mm;
SD, 1.8).26 As stated above, radical exposure vs partial
exposure in Boyd's study25 could not be considered as
excisional uncovering vs apically positioned ap, since
partial exposure included partial excisional uncovering
as well as apically positioned ap.
None of the included studies compared the periodontal outcome between canines uncovered with the
closed eruption technique and the apically positioned
ap technique. The most quoted study to prove the superiority in terms of periodontal health of the closed
technique over the apically positioned ap was that by
Vermette et al.23 However, even though their ndings

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Table V. Quality assessment of the studies included in the review

Quality assessment
Boyd,25 1984
Study design
Rating*
II-1
Internal validity
Initial assembly of comparable groups:
For RCTs: adequate
Yes
randomization, including
rst concealment and
whether potential
confounders were
distributed equally among
groups.
Yes
For cohort studies:
consideration of potential
confounders with either
restriction or measurement
for adjustment in the
analysis; consideration of
inception cohorts.
Maintenance of comparable
Attrition: no
groups (includes attrition,
crossovers, adherence,
contamination).
Crossover: NA
Adherence: NA
Contamination: NA
Important differential loss to
No
follow-up or overall high
loss to follow-up.
Measurements: equal, reliable,
Masking of outcome assessment:
and valid (includes masking
NR
of outcome assessment).
Clear denition of
Yes
interventions.
All important outcomes
Yes
considered.
Analysis:
For cohort studies:
NR
adjustment for potential
confounders
For RCTs: intention-toNR
treat analysis
Rating*
Fair

Tegsjo et al,26 1984

Kim et al,27 2007

II-2

II-2

NR

NA (split-mouth design with

patients serving as their own
controls)

NR

NA (split-mouth design with

patients serving as their own
controls)

Attrition: NR

Attrition: NA

Crossover: NA
Adherence: NA
Contamination: NA
NR

Crossover: NA
Adherence: NA
Contamination: NA
No

Masking of outcome assessment:

NR

Masking of outcome assessment:

NR

Yes

Yes

Yes

Yes

No

NA (split-mouth design)

No

NA (split-mouth design)

Fair

Fair

RCTs, Randomized controlled trials; NR, not reported; NA, not applicable.
*According to the US Preventive Services Task Force criteria.13

were considered unreliable because of the inclusion of

both canines and incisors, no direct comparison between
the 2 surgical techniques was done because of the sample's heterogeneity.
Limitations

The available evidence for this review came from only

3 studies. Sample sizes were rather small (20-50), and
none of the included studies provided an a priori sample
size calculation; this might cause an increased risk of
false-negative results and undermine the power of these

April 2016  Vol 149  Issue 4

studies. Because the included studies (1 clinical trial

without random allocation and 2 retrospective cohort
studies) did not receive high scores for quality of evidence, the risk of bias is high, and the evidence is rather
weak. Not every study included in the review established
pretreatment equivalence (age, sex, classication of occlusion, length of treatment, and difculty of surgical
exposure), thus increasing the risk of selection bias. A
detection bias may also exist because the periodontal
outcome assessors were not blinded to the treatments.
Finally, in the included studies, there was no mention

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Incerti-Parenti et al

or evaluation of the surgeons' experience, which can

affect the periodontal outcome of the surgical uncovering of unerupted maxillary canines.28
Review level

In addition to electronic databases, the reference lists

of relevant articles were consulted to identify articles
that should be included in the review. However, this
approach could lead to a citation bias because citing previous studies is not objective, and supportive and unsupportive studies may have been overcited. Unpublished
data sources (gray literature) were not searched. The potential for publication bias was not assessed.
Implications for clinical practice

No clear evidence currently exists favoring one surgical technique over the others to uncover labially
impacted canines in terms of periodontal outcomes.
Current recommendations about which surgical procedure is better for periodontal health are mainly based
on expert opinions. In this regard, the most quoted reference source is a study by Kokich.5 He stated that if there
is sufcient gingiva to provide at least 2 to 3 mm of
attached gingiva over the canine crown after its eruption, any of the 3 techniques can be used; if the gingiva
is insufcient, the only technique that predictably will
produce more gingiva is an apically positioned ap.
However, without an evidence-based recommendation,
the choice of the method to uncover labially impacted
canines remains at the discretion of each practitioner.
Implications for future research

Since currently available studies provide insufcient

data to determine which surgical technique used to uncover labially impacted canines gives the best periodontal outcome, further studies are recommended on
this topic. Specically, we recommend that future
studies should meet the following criteria: (1) welldesigned, adequately powered, randomized controlled
trials (with adequate randomization); (2) split-mouth
design or consideration of potential confounders (eg,
age, sex, classication of occlusion, length of treatment,
and difculty of surgical exposure); (3) outcomes: recession, periodontal probing depth, clinical attachment
level, width of keratinized gingiva, and crestal bone
loss; (4) blinding of outcome assessors; (5) outcomes assessed 3 months after removal of the xed appliances;
and (6) intention-to-treat analysis. Information
regarding the experience of the clinician performing
the surgery should also be provided. Since periodontal
outcome after canine uncovering with the closed technique has not been properly evaluated yet, research

471

should specically address the following issues: (1) periodontal outcomes of canines uncovered with the closed
eruption technique; (2) comparisons between the closed
technique and excisional uncovering; and (3) comparisons between the closed technique and the apically positioned ap technique.
CONCLUSIONS

The current literature is insufcient to determine

which surgical procedure is better for periodontal health
to uncover labially impacted canines. Excisional uncovering of labially impacted canines was reported to result
in less-favorable periodontal outcomes, whereas labially
impacted canines uncovered with the apically positioned
ap technique seemed to show periodontal outcomes
comparable with those of untreated teeth; none of the
included studies examined the periodontal outcome of
the closed eruption technique. Therefore, there is a definite need for more well-designed research, especially
regarding the comparison between the closed technique
and the apically positioned ap technique.
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