Surgical methods to uncover maxillary impacted canines

The following is a summary of an article done by Kokich that had shown the different techniques to uncover the maxillary impacted canines whether it was labially or palatally impacted.

Labial Impaction :

3 Techniques to uncover labial impactions  :

• Excisional Uncovering.
• Apical Repositioning Flap.
• Closed Eruption technique.

Evaluate 4 criteria in labially impacted canines :

1. Assess labiolingual position of canine :

   • If it is labially positioned use any of the 3 techniques because little bone pesent labially.
   • If it is in the center of the alveolous use Closed Eruption technique.
   • Other methods are difficult to perform because extensive bone might need to be removed occlusally.

2. Assess vertical position relative to mucogingival junction.

   • Apical to Mucoginigival junction :
     • Deep to MGJ      :   Closed Eruption
     • Just above MGJ  : Apically repositioned flap mainly / Closed technique can be used too.
   • Coronal to Mucogingival Junction use Any of the 3 techniques.
     

1. Evaluate amount of gingiva in the area of the impacted canine :

   • Insufficient ginigiva : Only Apically repositioned flap.
   • Sufficient to provide 2-3 mm of attached gingiva over canine :
     Any of the 3 techniques can be performed.

2. Evaluate mesiodestal position of the crown of the impacted canine :

   • If mesially inclined and it is over the root of the upper lateral incisor use Apically repositioned flap.
   •  Excisional or Closed Eruption technique are not recommended.

Palatal Impaction :

• If Not passed the mesial surface of lateral incisor Extraction of C will result in normal eruption
• If passed beyond the lateral incisor : No Self Correction.
• Uncovering usually is done within 6-9 months after alignment of maxillary dentition.
• After Surgical exposure -> traction is initiated orthodontically . ( Ballista loop can be used or overlay wire ).
• If the tooth was not uncovered properly, it could appear to the orthodontist that the tooth is not moving and perhaps could be ankylosed .The incidence of ankylosed maxillary canines is low.
• If insufficient bone was removed -> less tooth movement will occur.
• Sufficient bone removal down to the cementoenamel junction is recommended by Kokich.
• Kokich recommends earlier timing for uncovering palatally impacted canine before orthodontic treatment. In some cases in late mixed dentition.
• When dental follicle is removed while uncovering the impacted canine , tooth will move by pressure resorption.
• a full-thickness mucoperiosteal flap is elevated in the area of the impacted canine. All bone over the crown is removed down to the cementoenamel junction. The flap is repositioned, and a hole is made through the gingival flap . Occasionally, if the tooth is positioned high in the palate, a dressing is placed over the exposed area in the flap. Once the bone and tissue have been removed, these palatally displaced canines will erupt on their own . In about 6 to 8 months, the canines generally have erupted to the level of the occlusal plane. At that point, a bracket can be placed on the tooth, and the root can be moved through the bone as the crown is gradually translated into the dental arch.

Labial	Assess labiolingual position	Labially Positioned	Any of the 3 methods
		In the center of the alveolous use	Closed Eruption technique.
	Assess vertical position relative to mucogingival junction	Apical to Mucoginigival junction	If it is so deep Closed Eruption
			If it is Just above MGJ  Apically  repositioned flap mainly / Closed technique can be used.
		Coronal to Mucogingival Junction	Any of the 3 techniques.
	Evaluate amount of gingiva in the area of the impacted canine	Insufficient ginigiva	Only Apically repositioned flap.
		Sufficient to provide 2-3 mm of attached gingiva over canine.	Any of the 3 techniques.
	Evaluate mesiodestal position of the crown of the impacted canine	If mesially inclined and it is over the root of the upper lateral incisor	Apically repositioned flap.   Excisional or Closed Eruption technique are not recommended.
Palatal		If Not passed the mesial surface of lateral incisor	Extraction of C will result in normal eruption
		If passed beyond the lateral incisor	No Self Correction.
		a full-thickness mucoperiosteal flap is elevated. All bone is removed down to the cementoenamel junction. The flap is repositioned, and a hole is made through the gingival flap . if the tooth is positioned high in the palate, a dressing is placed over the exposed area in the flap.