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Transcript of Efectos periodontales de cirugía de caninos retenidos
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Periodontal status after surgical-orthodontictreatment 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 ca-
nines. Whereas the surgical technique used for tooth uncovering has been shown not to affect the nal peri-
odontal 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 surgical-
orthodontic treatment. Two reviewers independently screened the articles, extracted data, and ascertainedthequality 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 thecontrol group;
gingival recession,0.5 mm[SD, 1.0] vs1.5mm [SD, 0.8] in thecontrol group; and width of keratinizedgingiva,
2.6 mm [SD, 1.4] vs 4.1 mm [SD, 1.5] in the control group). Impacted canines uncovered with an apically posi-
tioned ap had periodontal outcomes comparable with those of untreated teeth. Conclusions: The current liter-
ature 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)
Maxillary canine impaction is a clinical condition
commonly encountered in dentistry. Approxi-mately 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 animportant role in the etiology of labial impactions:
Jacoby 4 found that only 17% of labially impacted ca-
nines had suf cient space to erupt. Orthodontic
mechanics to open the space for the canine crown might
lead to spontaneous eruption, but when space has beencreated and the canine does not erupt within a reason-
able time, surgical uncovering of the impacted toothshould be considered. Three techniques are generally
used to uncover labially impacted canines: excisionaluncovering (gingivectomy), apically positioned ap,and closed eruption.5
One fundamental indicator of a successful outcome
in the treatment of impacted canines is the nal peri-odontal status.6 A recent randomized clinical trial by
Parkin et al7 showed that exposure and alignment of palatally impacted maxillary canines has a small peri-
odontal impact that is unlikely to be clinically relevant, without signicant differences in periodontal health be-
tween the open and closed techniques. Labial impac-tions seem to be more challenging to manage withoutadverse periodontal problems, and the surgical tech-nique used to uncover the canine is thought to be criticalfor the nal periodontal health because it affects theamount of attached gingiva over the tooth crown aftereruption.8 However, the actual periodontal impact of the surgical technique used to uncover labially impactedcanines is still unclear; to date, no systematic review has
been undertaken on this topic.
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, Univer-
sity of Brescia, Brescia, Italy.dAssistant professor, Department of Neuroscience, University of Padua, Padua,
Italy.eAssociate professor, Unit of Orthodontics, Department of Biomedical and Neu-
romotor 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, [email protected].
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
463
SYSTEMATIC REVIEW
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The purpose of this study was to systematically re-
view the literature on the periodontal status of labially impacted canines after combined surgical-orthodontictreatment with different surgical approaches to clarify
whether there is suf
cient evidence to support one sur-gical technique over the others in terms of periodontalhealth.
MATERIAL AND METHODS
Eligibility was assessed on the basis of the followinginclusion criteria.
The population was patients receiving surgical treat-ment to correct labially impacted maxillary canines.
No restriction for age, malocclusion, or type of ortho-dontic treatment was applied. Studies including both
labial and palatal impactions were excluded becauseof the anatomic differences in the keratinized tissues
between the palatal and labial mucosae. Studiesincluding both incisors and canines were excluded
because of the differences in the etiology of their im-pactions.
The intervention was combined surgical-orthodontictreatment of labially impacted canines. At least 1 of the following surgical techniques had to be used in
the study: closed surgical technique, excisional un-covering (radical exposure), or apically positionedap.
For comparison, when 1 technique was considered,the untreated contralateral side had to be used asthe control. When 2 surgical techniques werecompared, no untreated control group was required.
Outcomes; studies were considered for inclusion if atleast 1 of the following parameters was evaluated.
1. Plaque accumulation: plaque volume on thedental surfaces. The Plaque Index by Silness
and Loe,9 scored with a 4-point scale (0-3), is widely used to assess plaque accumulation.
2. Gingival inammation: assessment of the in-ammatory conditions of the gingiva can be
based on visual inspection and bleeding of thegingival margin (Gingival Index)10 or on gingival
bleeding tendency alone (Gingival Bleeding In-dex)11 or bleeding tendency.12
3. Recession: distance from the cementoenamel junction (CEJ) to the gingival margin, with thegingival margin apical to the CEJ being positive,
and the gingival margin coronal to the CEJ beingnegative.
4. Periodontal probing depth: distance from thegingival margin to the location of the tip of aperiodontal probe inserted into the pocket.
5. Clinical attachment level: distance from the CEJto the location of the inserted probe tip.
6. Width of the keratinized gingiva: distance be-tween the most apical point of the gingival
margin and the mucogingival junction.7. Width of the attached gingiva: distance betweenthe mucogingival junction and the projection onthe external surface of the bottom of the gingivalsulcus. It is obtained by subtracting the peri-odontal probing depth from the width of the ker-
atinized gingiva.8. Crestal bone loss: distance between the CEJ and
the alveolar bone crest measured on intraoral ra-diographs.
Study designs: randomized controlled trials,
controlled clinical trials, and observational studies
(cohort and case-control studies) were considered forinclusion 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 theirinception to January 2015 for relevant studies: PubMed,
Cochrane Central Register of Controlled Trials, LILACS,andScopus. There were no language restrictions. To iden-tify the relevant studies the following search strategy wasused: Search ((impact* OR unerupt* OR ectopic*) AND
(labial* OR buccal* OR vestibular*) AND ((maxilla* OR up-per) AND (canine* OR cuspid*)) AND (surgery or surgi-cal*)); 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 “undu-plicate” the references by importing them into the refer-
ence management software “ Mendeley ” (http://www.mendeley.com/features/reference-manager/). Two au-thors (D.R.I., S.I-P.) independently screened titles andabstracts. For studies that appeared to be relevant, or
when a denite decision could not be made based onthe title or abstract alone, the full article was obtained
and independently examined by the reviewers fordetailed assessment against the inclusion criteria. Because of the dichotomous nature of the ratings(accept or reject), agreement between the assessors (in-terassessor reliability) was formally assessed using the
kappa statistic. Disagreements were resolved by discus-sion. When resolution was not possible, a third reviewer
(G.A-B.) was consulted.
Data items and collection
Data extraction included the following items: (1) rstauthor, year of publication, and location; (2) study
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design; (3) population characteristics (subjects enrolled,
mean age, and sex distribution); (4) intervention (surgi-cal exposure, orthodontic traction); (5) investigatedcomparisons; (6) follow-up of the study; (7) outcome
measures; (8) signi
cance 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. Dis-agreements were resolved by discussion. When resolu-tion was not possible, a third reviewer (G.A-B.) wasconsulted.
Quality assessment in the studies
Two authors (V.C., A.G.) were blinded to the authorsand the sources of each reference and independently as-
sessed the research design as well as a 3-category rating
of the internal validity of each study (according tocriteria that varied depending on the study design), asstated by the U.S. Preventive Services Task Force(Table I).13 Disagreements were resolved through
consensus. The Spearman rank correlation coef cient was applied to evaluate the agreement between theraters.
Data synthesis
The ndings of the studies included in the systematicreview were gathered. A quantitative synthesis usingformal statistical techniques such as meta-analysis
seemed inappropriate because the selected studies were too few, with nonrandomized designs and a lackof homogeneity in the study settings. Therefore, a narra-tive synthesis was carried out.
RESULTS
Study selection and characteristics
The Figure shows the ow of the literature search ac-cording to the PRISMA format.14 The comprehensivesearch 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 ef-fects on the periodontal tissues of 2 surgical approaches:
radical exposure (entire labial aspect of the crownexposed) and partial exposure (2-3 mm of keratinizedtissue maintained with either an apically positionedap 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 par-
tial exposure. Periodontal status (including plaque accu-mulation, gingival inammation, gingival recession, loss
of attachment, and width of attached gingiva) was eval-uated 6 to 24 months after removal of the xed appli-ances. The radical exposure group appeared to havemore gingival inammation, gingival recession, and
loss of attachment than both the contralateral untreatedcanine 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 box-and-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 untreatedcanines.
Kim et al27 evaluated the periodontal health of 23labially displaced canines, exposed with an apically posi-tioned ap technique. Periodontal outcomes, evaluatedat least 1 year after the surgery, were compared with
those of the contralateral untreated canines. Caninesexposed with an apically positioned ap, when
Table I. US Preventive Services Task Force rating of study quality
De nition 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 thatinvalidates 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 ev-
idence for the population and setting in which it was conducted;ycriteria for grading internal validity (limited to the study designs
of the studies included in the review) were reported in Table V.
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1.5; SD, 0.8 mm), and reduced width of keratinizedgingiva (radical exposure: mean, 2.6; SD, 1.4 mm; andcontrol: 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 out-comes between canines uncovered with the closed erup-tion technique and untreated canines. The excluded
studies on this topic had inconsistent results. Cresciniet al,6,16 using a closed surgical technique with tunneltraction, at a 3-year follow-up found no signicant dif-ferences 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) andcrestal 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 thesestudies were not conclusive because they included
both palatal and labial impactions6,16 or both incisorsand 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 un-likely to be clinically signicant.
For the apically positioned ap vs the control groups,the periodontal statuses of the canines were not signif-icantly different.26,27 Boyd25 failed to differentiate exci-sional uncovering from apically positioned ap (both
were included in the “partial exposure” group); there-fore, no conclusion could be drawn regarding the peri-odontal status after the apically positioned apapproach compared with untreated canines. Among
the excluded studies, Vermette et al,23 who analyzedthe distance from the gingival margin to the CEJ (with
negative recording indicating a gingival margin locatedapically to the CEJ), found that teeth uncovered with anapically positioned ap showed more apical gingivalmargins 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 mid-facial surface (apically positioned ap: mean, 10.1 mm;SD, 1.00 mm; and control: mean, 9.5 mm; SD, 0.98 mm;
Table III. Characteristics of included studies
Characteristics Boyd,25 1984 Tegsj €o et al,26 1984 Kim et al,27 2007
Participants
Inclusion criteria Unilateral labially impacted
maxillary canine
Unilateral labially impacted
maxillary canine
Labially impacted maxillary canine
Surgical exposure and orthodontic
alignment of the impacted
canine
Surgical exposure of the impacted
canine performed between
1977 and 1979
Surgical exposure of the impacted
canine through APF
All appliances removed for a
minimum of 6 months
Minimum recall period of 1 year
after the surgery
Subjects, n (% male) 24 (33%) 50 (44%) 20 (-)
Mean age (y) (SD, range) - (-, 15/22) at time of the study 12.9 (-, 10/18) at time of the
surgery
-
Intervention RE: entire crown exposed by the
window approach
RE: surgical uncovering; surgical
dressing for 1 week;
orthodontic traction
Full xed orthodontics; surgical
uncovering (APF); surgical
dressing for 1 week;
orthodontic traction
PE: 2-3 mm of keratinized tissue
maintained with either an APFor a tissue excision
APF: Surgical uncovering; surgical
dressing for 1 week;orthodontic traction
Comparisons RE vs CTR RE vs CTR APF vs CTR
PE vs CTR APF vs CTR
RE vs PE RE vs APF
Recall period (mo) 6-24 after removal of xed
appliances
30-56 after surgical exposure Minimum of 12 after surgery
Outcomes PI, GI, BT, REC, PPD, LA, WAG GBI, WKT (lab), PPD, REC PI, GI, PPD, WAG, clinical crown
length, bone loss
Study design Controlled clinical trial Retrospective cohort study 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 probingdepth; LA, loss of attachment; WAG,widthof attached gingiva; WKT ,
width of keratinized gingiva; lab, labial.
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Table IV. Periodontal outcomes reported in the included studies
Boyd,25 1984 Tegsj €o et al,26 1984
CTR RE PE
Signi cance only
P\0.05 CTR RE APF
Signi cance only
P\0.01 CTR *
PI 0.66 (SE, 0.143
GI NR NR NR RE.
CTR RE . PE
0.30 (SE, 0.108
BT NR NR NR RE . CTR
RE . PE
GBIb 7% 29% 7% RE . APF
RE . CTR
REC NR NR NR RE . CTR
RE . PE
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)
RE . CTR
PPD
Buccal 1.6 mm
(SD, 0.6 mm)y
1.6 mm
(SD, 0.4 mm)z
1.2 mm
(SD, 0.4 mm)
1.4 mm
(SD, 0.4 mm)
APF . RE
CTR . RE
1.76 mm
(SE, 0.092 mm
Mesial 1.9 mm(SD, 0.6 mm)y
2.2 mm
(SD, 0.7 mm)z
2.4 mm(SD, 0.6 mm)
2.1 mm(SD, 0.5 mm)
NS
Palatal 1.9 mm
(SD, 0.5 mm)y
2.0 mm
(SD, 0.5 mm)z
2.1 mm
(SD, 0.5 mm)
2.0 mm
(SD, 0.5 mm)
NS
Distal 2.0 mm
(SD, 0.6 mm)y
2.1 mm
(SD, 0.6 mm)z
2.6
(SD, 0.6 mm)
2.2 mm
(SD, 0.6 mm)
NS
LA NR NR NR RE . CTR
RE . PE
WKG 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
WAG NR 0.0 mm 3.67 mm
(SD, 1.72 mm)
NR 3.73 mm
(SE, 0.254 mm
Clinical
crown
length
9.01 mm
(SE, 0.418 mm
Apr i l 2 0 1 6
Vol 1
4 9
I s s ue 4
Ame
r i c anJ our nal of O r t h od ont i c s and D
e nt of ac i al O r t h ope d i c s
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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 posi-tioned 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 posi-tioned ap: mean, 2.3 mm; SD, 0.57 mm; and control:mean, 1.8 mm; SD, 0.71 mm; P \0.007), the facialaspect (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 positionedap: 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 caninesand incisors, and the inadequate sample was the reasonfor the exclusion of this study.
None of the included studies examined the differ-ences in periodontal outcomes between canines uncov-ered through excisional uncovering and the closederuption technique. Among the excluded studies, Oden-rick and Modeer18 detected a greater frequency of reces-sions (recession 5 gingival margin apical to the CEJ) in
teeth uncovered with excisional uncovering than inthose 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 inmillimeters), and no statistical analysis.
Excisional uncovering resulted in a worse periodontal
outcome than an apically positioned ap: gingivalinammation was more pronounced with the Gingival
Bleeding Index (radical exposure: 29%; apically posi-tioned 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 partialexposure” in Boyd's study 25 could not be considered as
“excisional uncovering vs apically positioned ap,” since“partial exposure” included partial excisional uncoveringas well as apically positioned ap.
None of the included studies compared the peri-odontal outcome between canines uncovered with the
closed eruption technique and the apically positionedap technique. The most quoted study to prove the su-periority in terms of periodontal health of the closedtechnique over the apically positioned ap was that by
Vermette et al.23 However, even though their ndings T a b l e
I V .
C o n t i n u e d
B o y d , 2
5 1 9
8 4
T e g s j € o e t a l , 2 6
1 9 8 4
K i m e t a l , 2 7
2 0 0 7
C T R
R E
P E
S i g n i c a n c e
o n l y
P \ 0 . 0
5
C T R
R E
A P F
S i g n i c a n c e
o n l y
P \ 0 . 0
1
C T R *
A P F *
S i g n i c a n c e
o n l y
P \ 0 . 0
5
B o n e l o s s
1 . 0 8 m m
( S E , 0 . 1 7 3 m m )
1 . 3 6 m m
( S E , 0 . 1 8 5 m m )
N S
D a t a a r e p r e s e n t e d a s m e a n s a n d s t a n d a r d d e v i a t i o n s u n l e s s o t h e r w i s e s t a t e d .
C T R , c o n t r o l g r o u p ; R E , r a d i c a l e x p o s u r e ; P
E , p a r t i a l e x p o s u r e ; A P F , a p i c a l l y p o s i t i o n e d a p ; P I , P l a q u e I n d e x ; G I , G i n g i v a l I n d e x ; B T , b
l e e d i n g t e n d e n c y ; G B I b ,
G i n g i v a l B l e e d i n g I n d e
x ( b u c c a l ) ; R E C ,
R e c e s s i o n ; P P D , p o c k e t p r o b i n g d e p t h ; L A
, l o s s o f a t t a c h m e n t ; W K T , w i d t h o f k e r a t i n i z
e d g i n g i v a ; W A G , w i d t h o f a t t a c h e d g i n g i v a ; N R , n o t r e p o r t e d ; N S , n o t s i g n i c a n t .
* D a t a a r e p r e s e n t e d a s m e a n s a n d s t a n d a r d e r r o r s ;
y R E c o n t r o l g r o u p ;
z A P F c o n t r o l g r o u p .
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were considered unreliable because of the inclusion of both canines and incisors, no direct comparison betweenthe 2 surgical techniques was done because of the sam-ple's heterogeneity.
Limitations
The available evidence for this review came from only 3 studies. Sample sizes were rather small (20-50), andnone of the included studies provided an a priori samplesize calculation; this might cause an increased risk of false-negative results and undermine the power of these
studies. Because the included studies (1 clinical trial without random allocation and 2 retrospective cohortstudies) did not receive high scores for quality of evi-dence, the risk of bias is high, and the evidence is rather
weak. Not every study included in the review establishedpretreatment equivalence (age, sex, classication of oc-clusion, length of treatment, and dif culty of surgicalexposure), thus increasing the risk of selection bias. Adetection bias may also exist because the periodontaloutcome assessors were not blinded to the treatments.
Finally, in the included studies, there was no mention
Table V. Quality assessment of the studies included in the review
Quality assessment Boyd,25 1984 Tegsj €o et al,26 1984 Kim et al,27 2007
Study design
Rating* II-1 II-2 II-2
Internal validity Initial assembly of comparable groups:
For RCTs: adequate
randomization, including
rst concealment and
whether potential
confounders were
distributed equally among
groups.
Yes NR NA (split-mouth design with
patients serving as their own
controls)
For cohort studies:
consideration of potential
confounders with either
restriction or measurement
for adjustment in the
analysis; consideration of inception cohorts.
Yes NR NA (split-mouth design with
patients serving as their own
controls)
Maintenance of comparable
groups (includes attrition,
crossovers, adherence,
contamination).
Attrition: no Attrition: NR Attrition: NA
Crossover: NA Crossover: NA Crossover: NA
Adherence: NA Adherence: NA Adherence: NA
Contamination: NA Contamination: NA Contamination: NA
Important differential loss to
follow-up or overall high
loss to follow-up.
No NR No
Measurements: equal, reliable,
and valid (includes masking
of outcome assessment).
Masking of outcome assessment:
NR
Masking of outcome assessment:
NR
Masking of outcome assessment:
NR
Clear denition of interventions.
Yes Yes Yes
All important outcomes
considered.
Yes Yes Yes
Analysis:
For cohort studies:
adjustment for potential
confounders
NR No NA (split-mouth design)
For RCTs: intention-to-
treat analysis
NR No NA (split-mouth design)
Rating* Fair Fair Fair
RCTs, Randomized controlled trials; NR , not reported; NA, not applicable.
*According to the US Preventive Services Task Force criteria.13
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or evaluation of the surgeons' experience, which can
affect the periodontal outcome of the surgical uncover-ing of unerupted maxillary canines.28
Review levelIn addition to electronic databases, the reference lists
of relevant articles were consulted to identify articlesthat should be included in the review. However, thisapproach could lead to a citation bias because citing pre-
vious studies is not objective, and supportive and unsup-portive studies may have been overcited. Unpublisheddata sources (gray literature) were not searched. The po-tential for publication bias was not assessed.
Implications for clinical practice
No clear evidence currently exists favoring one surgi-
cal technique over the others to uncover labially impacted canines in terms of periodontal outcomes.Current recommendations about which surgical proce-dure is better for periodontal health are mainly basedon expert opinions. In this regard, the most quoted refer-ence source is a study by Kokich.5 He stated that if there
is suf cient gingiva to provide at least 2 to 3 mm of attached gingiva over the canine crown after its erup-tion, any of the 3 techniques can be used; if the gingivais insuf cient, the only technique that predictably willproduce more gingiva is an apically positioned ap.
However, without an evidence-based recommendation,
the choice of the method to uncover labially impactedcanines remains at the discretion of each practitioner.
Implications for future research
Since currently available studies provide insuf cientdata to determine which surgical technique used to un-
cover labially impacted canines gives the best peri-odontal outcome, further studies are recommended on
this topic. Specically, we recommend that futurestudies should meet the following criteria: (1) well-designed, adequately powered, randomized controlledtrials (with adequate randomization); (2) split-mouth
design or consideration of potential confounders (eg,age, sex, classication of occlusion, length of treatment,and dif culty of surgical exposure); (3) outcomes: reces-sion, periodontal probing depth, clinical attachmentlevel, width of keratinized gingiva, and crestal boneloss; (4) blinding of outcome assessors; (5) outcomes as-sessed 3 months after removal of the xed appliances;
and (6) intention-to-treat analysis. Informationregarding the experience of the clinician performingthe surgery should also be provided. Since periodontaloutcome after canine uncovering with the closed tech-nique has not been properly evaluated yet, research
should specically address the following issues: (1) peri-
odontal outcomes of canines uncovered with the closederuption technique; (2) comparisons between the closedtechnique and excisional uncovering; and (3) compari-
sons between the closed technique and the apically posi-tioned ap technique.
CONCLUSIONS
The current literature is insuf cient to determine
which surgical procedure is better for periodontal healthto uncover labially impacted canines. Excisional uncov-ering of labially impacted canines was reported to resultin less-favorable periodontal outcomes, whereas labially
impacted canines uncovered with the apically positionedap 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 def-inite need for more well-designed research, especially regarding the comparison between the closed technique
and the apically positioned ap technique.
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