European Journal of Orthodontics, 2023, 45, 584–598

https://doi.org/10.1093/ejo/cjad039
Advance Access publication 29 August 2023
Systematic Review

Periodontal outcomes associated with impacted maxillary

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central incisor and canine teeth following surgical
exposure and orthodontic alignment: a systematic review
and meta-analysis
Jadbinder Seehra1,2, , Aminah Alshammari2, Fidaa Wazwaz1, Spyridon N. Papageorgiou3, ,
Jonathon T. Newton4, Martyn T. Cobourne1,2,*,
1
Centre for Craniofacial Development & Regeneration, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, Guy’s Hospital,
Floor 27, London SE1 9RT, United Kingdom
2
Department of Orthodontics, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, Floor 21, Guy’s Hospital, Guy’s and St
Thomas NHS Foundation Trust, London SE1 9RT, United Kingdom
3
Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Plattenstrasse 11, Zurich 8032, Switzerland
4
Population & Patient Health, Guy’s Hospital, Floor 18, Tower Wing, London SE1 9RT, United Kingdom
*
Corresponding author. Centre for Craniofacial Development & Regeneration, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, Guy’s
Hospital, Floor 27, London SE1 9RT, United Kingdom. E-mail:[email protected]

Abstract
Background: Maxillary incisor and canine teeth are commonly impacted and require multidisciplinary treatment to accommodate them in the
dental arch.
Objectives: To assess the periodontal outcomes of impacted maxillary central incisor and canine teeth, which have been successfully aligned
in the arch following surgical exposure and orthodontic traction with fixed appliance therapy.
Search methods: Systematic literature searches without restrictions were undertaken in eight databases.
Selection criteria: Studies reporting surgical interventions in combination with orthodontic traction with fixed appliance therapy to align im-
pacted maxillary incisors or canines published up to January 2023.
Data collection: Duplicate independent study selection, data extraction, and risk of bias assessment.
Analysis: Random-effects meta-analyses of aggregate data.
Results: Twenty-three studies (21 retrospective and 2 prospective) were included in the final analysis. Three studies reported outcomes for
maxillary central incisors and 20 reported outcomes for maxillary canines. For maxillary central incisors, all three studies were rated as being at
moderate risk of bias. For maxillary canines, 17 studies and 1 study were rated at moderate and high risk of bias, respectively. Both prospective
studies were rated at a low risk of bias. Meta-analyses comparing aligned impacted maxillary canines to their non-impacted contralateral coun-
terparts found the former had increased Plaque Index scores (mean difference [MD] 0.19; 95% confidence interval [CI] 0.03, 0.35; P = 0.03),
increased clinical attachment loss (MD 0.40 mm; 95% CI 0.17, 0.63; P = 0.01), increased pocket probing depth (MD 0.18 mm; 95% CI 0.07, 0.28;
P = 0.001), increased bone loss (MD 0.51 mm; 95% CI 0.31, 0.72; P < 0.001), and reduced keratinized gingival width (MD −0.31 mm; 95% CI
−0.61, −0.01; P = 0.04).
Conclusions: Limited evidence suggests that surgical exposure and orthodontic alignment of impacted maxillary central incisor or ca-
nine teeth, results in modest adverse effects in the periodontium. These findings should be viewed with caution as our certainty for these
outcomes is very low to low due to the bias and heterogeneity. Further well-conducted studies reporting patient centred outcomes are
required.
Registration: PROSPERO (CRD42020225639)
Keywords: Periodontal; surgical exposure; alignment; traction; canines; incisors

Introduction migration, and external root resorption of adjacent teeth

The maxillary incisor and canine are two of the most com- [3–5]. Moreover, their prominent position within the smile
monly impacted teeth in the permanent dentition after the arc can make the aesthetic consequences associated with the
third molars [1, 2]. Typically, abnormalities in their normal absence of these teeth quite considerable. To mitigate these
eruption present during childhood and early adolescence. complications, multidisciplinary treatment consisting of sur-
Their impaction can lead to localized disturbances in the gical exposure and concomitant orthodontic traction is often
developing occlusion such as reduction in arch length, undertaken to accommodate and align these teeth in the max-
illary arch [6, 7]. Alternative approaches include extraction

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please
email: [email protected]
J. Seehra et al. 585

followed by restorative replacement or space closure; how- Eligibility criteria

ever, both these approaches are associated with disadvan- Inclusion criteria
tages, including the life-long burden of a prosthesis or in the Based on the PICOS (Participants, Interventions, Comparison,
case of space closure, prolonged orthodontic treatment, and Outcome and Studies) format, the following eligibility criteria
retention. Based on this, to aid treatment decisions, estimates were utilized: (P) patients of any age, sex, or ethnicity who
for treatment outcomes for both impacted maxillary incisors present with a single unilateral anterior maxillary impacted
and canines are desirable.

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(unerupted) tooth in any clinical setting; (I) surgical inter-
Despite the obvious advantages of accommodating these ventions (open exposure, closed exposure or apically reposi-
teeth in the maxillary arch, this treatment modality is not tioned flap) in combination with orthodontic traction using
without potential risk to the periodontal tissues, which can fixed appliance therapy; (C) untreated contralateral fully
include alveolar bone loss, development of gingival pockets erupted tooth within the maxillary arch; (O) any clinical peri-
and gingival recession. The importance of maintaining a odontal outcomes including Clinical Attachment Loss (CAL;
minimum zone of attached gingiva has been debated within primary outcome; probing depth and gingival recession [23,
the literature [8, 9]. An adequate zone of attached gingiva 26]), Plaque Index (PI), Gingival Index (GI), Bleeding Index,
is thought to be associated with greater ability to withstand bone probing depth (subtracting the distance from cemento-
gingival inflammation and lower risk for developing gingival enamel junction to gingival margin from the distance gingival
recession [10, 11], while a healthy periodontium has been margin to bone [30]), Pocket Probing Depth (PPD; probing
proposed as a key indicator of treatment success for impacted depth measured from the base of the pocket to the gingival
teeth [12]. margin [7, 19–21, 23, 31]), marginal alveolar bone loss, gin-
Periodontal outcomes appear to be influenced by the pos- gival recession (distance from the cementoenamel junction to
ition [13] of the impacted tooth (buccolingually) and the type the gingival margin [20, 21, 26, 32, 33]), attached gingival
of surgical exposure performed. Open exposure and ortho- width, keratinized gingiva width (measured as the distance
dontic traction of impacted maxillary central incisors is as- from the free gingival margin to the mucogingival junction
sociated with significant reduction of the attached gingival [12, 21, 25, 32]), abnormal gingiva, and clinical crown length;
width, increase in clinical crown length, and alveolar bone (S) randomized clinical trials, retrospective and prospective
loss [14, 15]. Closed surgical exposure, which is thought to observational cohort studies (single group or comparative) or
more appropriately replicate normal tooth eruption [16] has case–control studies involving human participants.
also been reported to compromise the periodontal condi-
tion of aligned impacted incisors [15, 17]. Parallels can be
Exclusion criteria
drawn with the management of impacted maxillary canines.
Several retrospective studies have reported increased pocket Review articles, letters, case reports or series (<10 patients),
depth [7, 13, 18–23], reduction in both keratinized and at- opinion pieces, in vitro studies, and studies involving parti-
tached gingival levels [24, 25], reduction in alveolar bone cipants with any previous history of orthodontic treatment,
levels [7, 19, 25], and increased clinical crown length [25] pre-existing periodontal disease, medical conditions, and par-
for maxillary canines that have undergone surgical exposure ticipants undergoing growth modification were excluded.
and alignment. At the same time, existing evidence suggests
that the differences in periodontal outcomes for maxillary Information sources, search strategy, and study
impacted canines that have undergone either open or closed selection
exposure in conjunction with orthodontic traction are min- Eight electronic databases (MEDLINE searched via PubMed,
imal [26–28]. The Cochrane Library (CDSR, CENTRAL and DARE), OVID,
From a clinical aspect, providing an overall estimate of the Virtual Health Library (including Bibliography Brazilian
periodontal impact following surgical exposure and ortho- Dentistry and LILACS), Scopus, ISI Web of Knowledge,
dontic alignment of commonly impacted anterior maxillary Embase, and ClinicalTrials.gov) were searched with no lan-
teeth regardless of position or type of surgical intervention guage or publication date restrictions from inception up to 31
would be useful for both clinicians and patients. The aim of October 2021 and updated on 31 January 2023. Additionally,
this systematic review was to assess periodontal outcomes Directory of Open Access Journals, Digital Dissertations
associated with impacted (unerupted) maxillary central in- (searched via UMI Proquest), metaRegister of Controlled
cisor and canine teeth, which have been successfully aligned Trials and WHO trials search portal were searched manu-
in the maxillary arch following surgical exposure and ortho- ally. The search strategy was developed with the assistance
dontic traction with fixed appliance therapy, compared to of a healthcare librarian. Initial piloting of the search term
the contralateral normally erupted tooth within the same strategy resulted in a limited number of identified articles.
individual. On the recommendation of the healthcare librarian, broader
search terms were used to increase the chances of identifying
potentially relevant articles (Supplementary Table III).
Materials and methods Supplementary hand searching of the reference and citation
Protocol and registration lists of the full text articles that were eligible for inclusion was
The protocol for this review was devised a priori and registered also undertaken.
in PROSPERO (CRD42020225639), with reporting under-
taken in accordance with the updated Preferred Reporting Study selection, data items, and collection
Items for Systematic reviews and Meta-Analyses statement All search results were imported to Rayyan software (www.
(Supplementary Table I PRISMA checklist) [29]. All post-hoc rayyan.ai) and two authors (J.S. and A.A.) independently
changes to the protocol have been reported (Supplementary screened titles and abstracts after the removal of duplicates
Table II). with complete agreement achieved. Subsequently, the full text
586 European Journal of Orthodontics, 2023

of studies was reviewed against the eligibility criteria and any was undertaken by including only bias free or the most pre-
disagreements were resolved by discussion with a third au- cise studies.
thor (M.T.C.). Data extraction was undertaken independently Possible sources of heterogeneity were identified by pre-
by three authors (J.S., A.A., and F.W.) using a pre-piloted data specified mixed-effects subgroup analyses and random-effects
collection form. Any disagreements were resolved by dis- meta-regression, if at least 5 studies were included for a spe-
cussion with a fourth author (M.T.C.) until consensus was cific comparison. Pre-defined subgroup/meta-regression ana-
reached. The following variables were collected: study char- lyses included subsets according to patient (age and gender),

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acteristics (design, setting, country), mean age and gender, position of the canine (buccal and palatal), and type of sur-
type of impacted tooth and position (buccal, palatal or not gery (open and closed exposure).
reported), number of impacted teeth and side (right or left), Within- and across-studies risk of bias was incorporated in
radiographic investigations performed, position of the im- the results of the meta-analysis in formulating clinical recom-
pacted tooth determined radiographically, root developmental mendations and by conducting appropriate sensitivity ana-
stage, type of surgical intervention, site of eruption, duration lyses. The quality of clinical recommendations was rated using
of treatment, periodontal outcomes, and reported assessment Grades of Recommendations, Assessment, Development,
of intra and/or inter-examiner measurement reliability. Evaluation (GRADE) [39] and revised summary of find-
ings tables [40]. Forest plots were augmented with contours
Risk of bias assessment denoting the magnitude of observed effects to assess hetero-
The risk of bias of randomized, non-randomized compara- geneity, clinical relevance, and imprecision.
tive and single-group cohort studies were assessed using the
revised Cochrane risk of bias tool for randomized trials (ROB Sensitivity analyses
2) [34], ROBINS-I (Risk Of Bias In Non-randomised Studies Robustness of the results was checked with sensitivity analyses
of Interventions) [35] and Newcastle-Ottawa scale [36], re- based on (i) inclusion/exclusion of studies with methodo-
spectively. All assessments were undertaken independently by logical shortcomings or signs of bias; (ii) inclusion/exclusion
two authors (J.S. and F.W.) with any disagreements resolved of non-randomized trials; (iii) improvement of the GRADE
by discussion with a third author (M.T.C.). Complete agree- classification; and (iv) inclusion/exclusion of large-scale
ment was achieved. studies (cut-off arbitrarily set at 30 impacted canines).

Data synthesis and summary measures

To optimize data yield, we attempted to include all studies Results
independently of reporting-completeness and data was calcu- Study selection and characteristics
lated by ourselves, where necessary. Multiple similar arms from
The literature search identified 973 articles (Fig. 1). After re-
a study were pooled prior to synthesis to avoid arm-clustering.
moval of duplicates, 632 titles and abstracts were screened
The odds ratio for categorical and the mean difference (MD)
and a total of 87 full-text studies were subsequently evalu-
for continuous outcomes, together with the corresponding
ated with a further 38 excluded. Forty-nine full texts were
95% confidence intervals (CIs), were used as effect measures
reviewed against the eligibility criteria with reasons for ex-
for pairwise (two-group) comparisons. Adjusted effect sizes
clusion reported (Supplementary Table IV) and 23 studies (21
and their corresponding adjusted standard errors were cal-
retrospective and 2 prospective) were included in the final
culated to account for dependency (clustering) of observa-
analysis (Tables 1–4). Three studies reported outcomes for
tions within the same mouth by back-calculating correlations
maxillary central incisors and 20 reported outcomes for max-
from studies providing raw data. A random-effects model was
illary canines.
chosen a priori (based on clinical/statistical reasoning) and a
REML-estimator [37] with the Hartung–Knapp modification
Maxillary central incisors
[38] was used to calculate the average distribution of effect
sizes across included studies, while 95% prediction intervals From the three included retrospective studies on maxillary
were calculated for meta-analyses involving ≥3 studies to in- central incisors, one (33%) was conducted in private prac-
corporate heterogeneity and give a possible range of clinical tice, while the clinical settings in the other studies were not
outcomes that can be expected. All P-values were two sided reported. The total number of patients across the three studies
(α = 0.05, except for between-study or between-subgroups was 54, with a predilection for females (n = 38; 69%). The
heterogeneity tests, where α = 0.10) and all analyses were total number of impacted incisors was 64 with one study
conducted by one author (S.N.P.) in R (version 4.0.4), with using open exposure, one study closed exposure, and one
an openly provided dataset (doi: 10.5281/zenodo.7660920). using both techniques. The reliability of periodontal meas-
urements was undertaken in two of the three studies (67%),
Additional analyses, risk of bias across studies, and while none of them reported adverse events (Tables 1 and 2).
quality of evidence
The extent and impact of between-study heterogeneity was Maxillary canines
assessed visually on the forest plots and by calculating the τ² From the 20 included studies, 18 studies were retrospective
and the I² statistics (with their 95% CIs), respectively, while and 2 were prospective. Among 8 of the 18 included retro-
also considering localization and/or direction of the hetero- spective studies reporting the clinical setting, 4 were con-
geneity on the forest plot. If ≥10 studies were included, re- ducted in a university (50%), 2 in a private practice (25%),
porting biases (including the possibility of small-study effects and 2 in multiple sites (25%). The majority of studies were
and publication bias) were assessed via contour-enhanced conducted in European countries (n = 13; 72%), followed
funnel-plots and Egger’s test. If the presence of bias was de- by the USA (n = 2; 11%), Israel, South Korea, and Iran (n
tected, an explanation was sought and a sensitivity analysis = 1; 6% each). The total number of patients across the 18
J. Seehra et al. 587

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Figure 1. PRISMA flow diagram for study selection.

Table 1. Study characteristics for studies reporting periodontal outcomes for the orthodontic alignment of impacted maxillary central incisors (n = 3)

Study Design; setting; Patients (M/F); Type of imp tooth Side of Radiographs
countryb agea (CI): Position P/B/NR impacted teeth

Becker et al [17]. rNRS; NR; IL 21 (6/15); 17.5 Centrals: NR 21: NR Periapical

Chaushu et al [14]. rNRS; Pract; IL 11 (4/8); NR Centrals: NR 21: NR Orthopantomogram/periapical
Chaushu et al [15]. rNRS; NR; IL 22 (7/15); NR Centrals: NR 22: NR Periapical

B, Buccal; F, female; M, male; NR, not reported; P, Palatal; Pract, private practice; rNRS, retrospective non-randomized study.
a
Patient age given as mean.
b
Countries are given with their ISO Alpha-2 codes.

Table 2. Study characteristics for studies reporting periodontal outcomes for the orthodontic alignment of impacted maxillary central incisors (n = 3)

Study Rad position (Vertical/axial/ Developmental Intervention Site of Duration Rx Reliability (Y/N): Adverse
buccal/palatal) stage (IC/C) (Surgical) eruption (A/F) (months) (B/C/NR) events

Becker et Labial; In the crest NR Closed NR NR Y:C NR

al [17].
Chaushu Vertical zone (relative to the root of NR Open NR 12 Y:C NR
et al [14]. CCI): apical [5]; middle [6]; coronal [1]
Chaushu NR NR G1: Open NR NR NR NR
et al [15]. [11]
G2: Closed
[11]

IC, Incomplete; C, Complete; NR, not reported; Y, Yes; N, No; Reported reproducibility/reliability of periodontal outcome measurements (Reliability): B,
Binary data; C, Continuous data; AE, adverse effects, A; Attached mucosa, F; Free mucosa, Rx; treatment.

included studies was 645, with a mean age of 22.9 years The type of surgical intervention was as follows: closed
(from the 17 studies reporting age) and predominance for exposure (n = 8; 53.3%), open exposure (n = 3; 20.0%),
female patients (n = 392/583; 67.2% from the 16 studies closed and open exposure (n = 2; 13.3%), open exposure
reporting gender. The total number of impacted maxillary and apically repositioned flap (n = 1; 6.7%), closed ex-
canines was 608 (n = 17) and among these, 385 (n = 12) posure and apically repositioned flap (n = 1; 6.7%). The
were palatally and 173 (n = 5) were buccally positioned. reliability of periodontal measurements was undertaken
588 European Journal of Orthodontics, 2023

in nine studies (n = 9; 50%) but not reported in the re- non-randomized study [21] and randomized clinical trial
maining nine studies (Tables 3 and 4). [26] were both rated at a low risk of bias (Tables 7 and 8)
One non-randomized prospective study was under- (Supplementary Table VI).
taken in a university setting in Lithuania [21] and in-
cluded 43 patients (81% female; mean age 22.0 years)
with 43 palatally impacted canines treated with closed Results of individual studies, data synthesis,
(49%) or open exposure (51%). One randomized clinical reporting biases, and certainty of evidence

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trial conducted in a hospital setting in the UK [26] investi- For maxillary central incisors: direct comparisons between
gated 62 patients (69% female) with palatal impacted ca- aligned impacted central incisors and spontaneously erupted
nines treated with closed (47%) or open exposure (53%) contralateral incisors or between open and closed expos-
(Tables 3 and 4). ures were performed from either individual single studies or
meta-analyses of 2 studies (Supplementary Table VII). Based
on single studies, compared to the contralateral erupted in-
Risk of bias of included studies cisor, aligned central incisors showed increased crown length
The risk of bias assessment for the included studies is shown (distance measured between the incisal edge and the gingival
in Tables 5–8. For maxillary central incisors, all three studies margin [14, 15, 17]) (MD 0.67 mm), GI (MD 0.23) and PPD
[14, 15, 17] were rated as being at moderate risk of bias (MD 0.23 mm), while they showed reduced bone level (MD
(Table 5). For maxillary canines, 17 studies [4, 7, 12, 13, 16, −5.15%) and attached gingival width (calculated by sub-
18–20, 22–25, 30–33, 41, 42] were rated as being at mod- tracting the mid-labial pocket depth from the width of the
erate risk of bias and 1 study was rated as high risk of bias keratinized gingiva [14, 15, 17]) (MD −0.85 mm). Single
[13] (Table 6). Across these studies, common reasons for studies comparing exposure techniques showed that central
downgrading internal validity were due to lack of represen- incisors treated with open exposures had higher odds for ab-
tativeness, comparability and duration of outcome (Tables normal gingiva (recorded when there was recession or irregu-
5 and 6) (Supplementary Table V). The single prospective larity [14]) (OR 11.94), reduced bone levels (MD −7.50%)

Table 3. Study characteristics for studies reporting periodontal outcomes for the orthodontic alignment of impacted maxillary canines (n = 20)

Study Design; setting; Patients (M/F); Impacted teeth; Number of Radiographs

countrya ageb type; position teeth; side

Becker et al [7]. rNRS; NR; IL 23 (9/14); 12.5 C; P 23; NR PA

Blair et al [4]. rNRS; NR; GB 25 (3/22); NR C; P 30; 15L; 15R PA
Caprioglio et al [41]. rNRS; NR; IT 33 (9/24); 16.3 C; P 33; NR OPT
Crescini et al [16]. rNRS; NR; IT 15 (4/11); 14.8 C; 8P, 7B 15; 5L,10R OPT
Crescini et al [12]. rNRS; Pract; 125 (31/94); 16.9 C; 78P, 47B 125; 54L, 71R CBCT; LC; OPT; PA; USO
IT
Evren et al [31]. rNRS; Uni; TR 30 (9/21); 11.4 C; 15P, 15B NR PA
Hansson and Linder-Aronson [13] rNRS; NR; SE 18 (5/13); 17.6 C; P 18; 11L, 7R NR
Hansson and Rindler [22] rNRS; Hosp/ 42 (15/27); 21.6 C; P 42; 17L, 25R BW
Pract; SE
Lee et al [25]. rNRS; Uni; KR 54 (21/33); 12.9 C; B 54; NR OPT; PA
Oz and Ciger [19] rNRS; Uni; TR 20 (11/9); 15.3 C; P 20; NR CBCT
Parkin et al [26]. RCT; Hosp; 62 (19/43); NR C; P 62; 23L, 39R PA
GB
Quirynen et al [33]. rNRS; Uni/ 38 (12/26); 22 C; NR 26; NR PA; USO
Pract; BE
Smailiene et al [21]. pNRS; Uni; LT 43 (8/35); 19.7 C; P 43; NR OPT; PA
Szarmach et al [18]. rNRS; NR; PL 24 (5/19); 18.4 C; NR 24; NR OPT
Tegsjo et al [32]. rNRS; NR; SE 50 (22/28); 12.9 C; B 50; NR NR
Vermette et al [30]. rNRS; NR; US 30 (NR); 12.8 CI/LI/C; B 30; NR OPT; PA
Wisth et al [23]. rNRS; NR; 34 (15/19); 17.3 C; P 34; 14L, 20R NR
NO
Woloshyn et al [42]. rNRS; Pract; 32 (NR); 17.0 C; P 32; NR BW; OPT; PA
US
Zafarmand and Gholami [24] rNRS; NR; IR 20 (10/10); 16.7 C; P 20; NR OPT
Zasciurinskiene et al [20]. rNRS; Uni; LT 32 (10/22); 18.2 C; P 32; NR OPT

B, buccally; BW, bitewing radiograph; C, canine; CBCT, cone-beam computed tomography; CI, central incisor; F, female; Hosp, hospital; L, left; LC, lateral
cephalogram; LI, lateral incisor; M, male; NR, not reported; OPT, orthopantomogram; P, palatally; PA, periapical radiograph; pNRS, prospective non-
randomized study; Pract, practice; R, right; RCT, randomized clinical trial; rNRS, retrospective non-randomized study; Uni, university clinic.
a
Countries given with their ISO alpha-2 codes.
b
Patient age given as mean.
J. Seehra et al. 589

Table 4. Study characteristics for studies reporting periodontal outcomes for the orthodontic alignment of impacted maxillary canines (N = 20)

Study Radiographic position Develop-mental Intervention Site of Duration Reliability (Y/N): AE

stage (IC/C) (Surgical) eruption (mos) (B/C/NR)

Becker et al [7]. NR NR Closed NR 17.9 Y:C NR

Blair et al [4]. NR NR Open NR NR NR NR

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Caprioglio et al a
Axial (Alpha angle), NR Closed NR 29.0 NR NR
[41]. distance and sectors
Crescini et al [16]. a
Alpha angle NR Closed Alveolar 22.0 Y:C NR
ridge
Crescini et al [12]. a
Alpha angle NR Closed Alveolar 20.6 NR NR
ridge
Evren et al [31]. NR NR Closed NR 46.8 (P) Y:C NR
42.2 (B)
Hansson and NR NR NR NR 21.0 NR NR
Linder-Aronson [13]
Hansson and NR NR G1: Closed NR 22.0 Y:C NR
Rindler [22] [11]
G2: Open
[31]
Lee et al [25]. Axial (alpha angle), Vertical NR Closed NR 30.3 Y:C NR
(Depth), Sector. (Nolla stage)
Oz and Ciger [19] NR NR NR NR NR NR NR
Parkin et al [26]. NR NR G1: Open NR G1: 10.2 Y:C NR
[33] G2: 13.2
G2: Closed
[29]
Quirynen et al [33]. NR NR Closed NR NR NR NR
Smailiene et al [21]. a
Horizontal and vertical NR G1: Closed NR G1: 32.2 NR NR
[21] G2: 28.4
G2: Open
[22]
Szarmach et al [18]. a
Vertical: I [2], II [5], III [5], NR G1: Closed NR 22.2 NR NR
IV [7], V [5] [20]
G2: Open
[4]
Tegsjo et al [32]. NR NR G1: Open NR NR NR NR
[21]
G2: APF
[29]
Vermette et al [30]. NR G1: Closed NR G1: 28.5 Y:C NR
[12] G2: 28.2
G2: APF
[18]
Wisth et al [23]. NR NR Open NR 18 Y:C NR
Woloshyn et al [42]. Axial angle NR NR NR 30.0 Y:C NR
Zafarmand and NR NR Open NR NR NR NR
Gholami [24]
Zasciurinskiene et a
Horizontal and vertical NR Closed NR 17.1 Y:C NR
al [20].

Design (rNRS, retrospective Non-Randomized Study; pNRS, prospective Non-Randomized Study; pRS, prospective Randomized Study); setting (Hospital,
University, Practice); country. Patients (N); Gender (M/F); Mean age months (age). Type of impacted maxillary tooth (Type of imp tooth): central incisor
(CI); Lateral incisor (LI); Canine (C); Position (Palatal/Buccal/NR). Number of impacted teeth (N of imp teeth); Side (Right/Left/NR). Radiographs (Rads):
Periapical (PA); Upper standard Occlusal (USO); Orthopantogram (OPT), Cone Beam Computed Tomography (CBCT). Radiographic position (Rad
position): Vertical(V); Axial (A); Buccal (B); Palatal(P) or classification a(Data from Ericson et al [43].). Developmental stage: incomplete root (IC), complete
root (C). Intervention. Site of eruption: Attached mucosa (A); Free gingival mucosa (F). Duration of treatment (overall to align impacted teeth and removal
of appliances) (months). Reported reproducibility/reliability of periodontal outcome measurements (Rel): Yes (Y)/No (N); Binary data (B), Continuous data
(C), Not Reported (NR); AE, adverse effects.

and increased crown length (MD 1.37 mm) compared to inci- could not be pooled in meta-analysis (Supplementary Table
sors treated with the closed exposure. VIII) and found reduced bone levels (MD 0.59 mm), increased
For maxillary canines: direct comparisons between aligned bleeding on probing (MD 0.10), increased bone probing
impacted maxillary canines and spontaneously erupted depth (MD 0.21 mm) and gingival scarring (evidence of soft
contralateral canines were performed in single studies that tissue bands [30]) (OR 67.36). No consistent differences were
590 European Journal of Orthodontics, 2023

Table 5. Risk of bias assessment of single-treatment cohort studies on impacted central incisors using the Newcastle-Ottawa Scale

Study Representativeness Selection of the Ascertainment Changes Comparability Assessment Duration Adequacy ★
non-exposed of exposure in of outcome of outcome of outcome
outcome

Becker et al [7]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6

Downloaded from https://academic.oup.com/ejo/article/45/5/584/7254682 by Universidad de Granada - Historia de las Ciencias user on 19 October 2023
Chaushu et al [14]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Chaushu et al [15]. ◯ (c) ★ (a) ★ (a) ★ (a) ★★ (a) (b) ★ (a) ★ (a) ★ (a) 8

Table 6. Risk of bias assessment of single-treatment cohort studies on impacted canines using the Newcastle-Ottawa Scale

Study Representativeness Selection Ascertainment Changes Comparability Assessment Duration Adequacy ★

of the of exposure in of outcome of of
non- outcome outcome outcome
exposed

Becker et al [7]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7

Blair et al [4]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Caprioglio et al ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
[41].
Crescini et al [16]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Crescini et al [12]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Evren et al [31]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Hansson and ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ◯ ★ (a) 5
Linder-Aronson [13]
Hansson and ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Rindler [22]
Lee et al [25]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Oz and Ciger [19] ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ◯ (c) ★ (a) 6
Quirynen et al [33]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Szarmach et al [18]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Tegsjo et al [32]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ◯ (c) ★ (a) 6
Vermette et al [30]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Wisth et al [23]. ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Woloshyn et al [42]. ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 7
Zafarmand and ◯ (c) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ★ (a) ★ (a) 6
Gholami [24]
Zasciurinskiene et ★ (b) ★ (a) ★ (a) ★ (a) ◯ ★ (a) ◯ (c) ★ (a) 6
al [20].

The NOS assess the following domains of study quality: participant selection (four items), comparability (one item), and outcome (three items). Each study
is awarded one star for each item in both the participant selection and outcome domains, and a maximum of two stars for comparability.

Table 7. Risk of bias assessment of comparative multiple-treatment cohort studies on impacted canines using the ROBINS-I tool

Bias due to/in…

Study Confounding Selection of Classification Deviations Missing Measurement Selection of Overall

participants of from intended data of outcomes the reported risk of
into the study interventions interventions result bias

Smailiene Low Low Low Low Low Low Low Low

et al [21].

Table 8. Risk of bias assessment of randomized clinical trials on impacted canines using the ROB 2.0 tool

Study Randomization Deviations from Missing Measurement Selection of the Overall

process intended interventions outcome data of the outcome reported result risk of bias

Parkin et al [26]. Low Low Low Low Low Low

J. Seehra et al. 591

found from single studies comparing open to closed exposure Tables XI–XIII). Male patients were associated with greater
techniques (Supplementary Table IX). bone loss, less keratinized gingiva width, and greater gingival
Meta-analyses comparing aligned impacted maxillary ca- recession than female patients. Furthermore, increasing age
nines to their non-impacted contralateral counterparts (Table was significantly associated with increased gingival recession
9) found the former had increased PI (n = 5; MD 0.19; 95% (Supplementary Table XI).
CI 0.03, 0.35; P = 0.03), increased CAL (n = 4; MD 0.40 Significant subgroup differences were found based on the lo-
mm; 95% CI 0.17, 0.63; P = 0.01; Fig. 2), increased PPD (n calization (palatal or buccal) of the impacted canine, with pal-

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= 18; MD 0.18 mm; 95% CI 0.07, 0.28; P = 0.001; Fig. 3), atal impacted canines showing greater PPD but less gingival
increased bone loss (n = 8; MD 0.51 mm; 95% CI 0.31, 0.72; recession compared to buccal impacted ones (Supplementary
P < 0.001; Fig. 4), and reduced keratinized gingival width (n Table XII). No significant differences were found for any of the
= 5; MD −0.31 mm; 95% CI −0.61, −0.01; P = 0.04; Fig. 5). parameters between open and closed exposure (Supplementary
Secondary analysis using multiple measurement sites per Table XIII). Egger’s test for the only meta-analysis with ≥10
tooth to compare aligned impacted to non-impacted contra- studies (PPD) suggested funnel plot asymmetry (Supplementary
lateral teeth indicated that differences were found mostly Table XIV), which was confirmed visually (Fig. 6). The influence
mesially and distally (bone levels) and mesiobuccally or of these small-study effects were further investigated by dividing
mesiopalatally (CAL and PPD) (Supplementary Table X). the sample by precision of the estimates (Supplementary Table
XIV) that indicated no significant difference (P = 0.14) between
studies at the top and the bottom of the funnel plot (most and
Additional analyses least precise studies, respectively). Sensitivity analyses according
Subgroup analyses and meta-regression analyses were used to to sample size and type of study (prospective and retrospective)
investigate potential sources of heterogeneity (Supplementary were undertaken (Supplementary Table XV). A significant

Table 9. Meta-analyses of outcomes compared between impacted and contralateral canines (main analysis)

Nr Treatment n MD (95% CI) P Tau2 (95% CI) I2 (95% CI) Prediction

1 Plaque Index 5 0.19 (0.03, 0.35) 0.03 0.01 (0, 0.16) 56% (0%, 84%) −0.14, 0.52
2 Sulcus Bleeding Index 2 SMD 0.28 (−2.92, 3.47) 0.47 0.06 (-) 44% (-) -
3 Gingival Index 4 0.19 (−0.08, 0.47) 0.11 0.02 (0, 0.39) 79% (44%, 92%) −0.56, 0.94
4 Clinical Attachment Level 4 0.40 (0.17, 0.63) 0.01 0.02 (0, 0.28) 73% (24%, 90%) −0.21, 1.02
5 Pocket Probing Depth 18 0.18 (0.07, 0.28) 0.002 0.04 (0.02, 0.10) 89% (84%, 92%) −0.25, 0.60
6 Bone level 8 0.51 (0.31, 0.72) <0.001 0.06 (0.02, 0.23) 95% (92%, 97%) −0.10, 1.13
7 % bone coverage 3 −5.19 (−11.34, 0.95) 0.07 5.84 (1.38, >100) 96% (90%, 98%) −40.86, 30.47
8 Crown length 4 0.54 (−0.32, 1.39) 0.14 0.26 (0.06, 4.06) 92% (82%, 96%) −1.93, 3.00
9 Width of attached gingiva 7 −0.15 (−0.49, 0.19) 0.32 0.11 (0.04, 0.64) 88% (78%, 94%) −1.09, 0.78
10 Width of keratinized gingiva 5 −0.31 (−0.61, −0.01) 0.04 0.04 (0, 0.50) 66% (11%, 87%) −1.01, 0.40
11 Gingival recession 7 0.19 (−0.01, 0.40) 0.06 0.04 (0.02, 0.23) 92% (86%, 95%) −0.38, 0.77
12 Malposition 2 6.49 (<0.01, >100) 0.21 0.26 (-) 31% (-) -
13 Root length 2 −1.19 (−8.75, 6.37) 0.29 0.64 (-) 90% (-) -
14 Gingival recession 2 OR 7.72 (0.21, >100) 0.08 0 (-) 0% (-) -

CI, confidence interval; MD, mean difference; OR, odds ratio; n, studies; SMD, standardized mean difference.

Figure 2. Forest plot for single-group meta-analysis of clinical attachment level (aligned maxillary canines).
592 European Journal of Orthodontics, 2023

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Figure 3. Forest plot for single-group meta-analysis of pocket probing depth (aligned maxillary canines).

Figure 4. Forest plot for single-group meta-analysis of loss of bone level (aligned maxillary canines).

difference for the comparison of small versus large studies for keratinized gingiva width compared to no effect on gingiva
gingival recession was observed, where small studies showed width found from prospective studies (−0.40 and +0.13 mm,
inflated values of recession compared to large studies (0.35 respectively; Supplementary Table XV).
and 0.14 mm, respectively). Additionally, retrospective studies The overall certainty of the available evidence as per
showed significantly worse outcomes in terms of reduced GRADE recommendations was appraised across different
J. Seehra et al. 593

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Figure 5. Forest plot for single-group meta-analysis of width of keratinized gingiva (aligned maxillary canines).

confirmed the previously reported reduced bone levels for

impacted incisors but also added findings of increased clin-
ical crown length, reduced attached gingival width, and in-
creased PPD compared to spontaneously erupted maxillary
incisors. Additionally, impacted incisors treated with an open
exposure protocol were associated with increased odds for in-
creased clinical crown length and bone loss compared to inci-
sors treated with a closed exposure protocol. However, these
findings should be viewed with caution as they are based on
three single studies (Supplementary Table VII).
The majority of included studies assessed palatal impacted
canines and their study cohorts showed a predilection for
female patients, which is consistent with the demographics
of this dental developmental anomaly [6]. Compared to the
spontaneously erupted contralateral maxillary canine, the
aligned impacted maxillary canines showed higher PI, greater
Figure 6. Funnel-plot asymmetry (Reporting biases for pocket probing CAL and PPD, increased bone loss and a reduced keratin-
depth). ized gingiva width (Table 9). Previous systematic reviews
have assessed outcomes for buccal [28], palatal [27] and im-
comparisons and periodontal outcomes between orthodon-
pacted [45] canines following various surgical interventions.
tically aligned impacted maxillary canines and spontan-
In a qualitative assessment of three studies, no clear evidence
eously erupted contralateral teeth (Table 10). All outcomes
was available regarding the type of surgical intervention and
were downgraded by two levels due to methodological issues
optimal periodontal outcomes for buccally impacted canines
that could potentially introduce bias. The outcomes pocket
[28]. Conversely, based on the qualitative assessment of nine
probing depth and keratinized gingiva width were further
studies comparing outcomes for palatal canines that have
downgraded due to high between-studies heterogeneity that
undergone either open or closed surgical exposures, no differ-
could also influence our decision about the effect of treat-
ence in periodontal outcomes between both procedures were
ment (i.e. studies lying on both sides of the forest plot). This
reported [27]. In summary, based on the findings of these re-
means that future studies might change our confidence on
views [27, 28, 45], no consistent differences in periodontal
both the direction and magnitude of the effect of orthodontic
outcomes regardless of the type of canine impaction and sur-
exposure/traction of impacted maxillary canines.
gical intervention undertaken was evident. The similarity in
the findings of these reviews could be attributed to the vari-
Discussion ation of the assumed primary outcomes.
More recently, a quantitative review of impacted teeth re-
Interpretation of the results in the context of other ported that compared to the spontaneously erupted contra-
evidence lateral tooth there was a worsening of GI scores, and a slight
A previous qualitative review of impacted maxillary incisors increase in PPD following surgical exposure and orthodontic
having undergone surgical exposure with orthodontic trac- alignment. However, there was no difference in PI scores or
tion reported reduced bone support and labial bone thick- the attached keratinized tissue width [46]. The findings of
ness compared to spontaneously erupted maxillary central the current review appear to contradict these findings, with
incisors [44]. However, this review was limited to English an increased PI score and reduced keratinized gingival width
studies and the grey literature was not searched, which might evident with aligned impacted maxillary canines. Differences
have introduced a certain degree of bias. The current review in the reported outcome estimates could be attributed to the
594 European Journal of Orthodontics, 2023

Table 10. Summary of findings table according to the GRADE approach

Anticipated absolute effects (95% CI)

Spontaneous eruption Contralateral Difference for Quality of the What happens for impacted canines
Studies (patients) caninea impacted canines evidence (GRADE)b

Clinical Attachment 0.90 mm 0.40 mm more ⊕◯◯◯ low c

Probably higher clinical attachment loss

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level (0.17 to 0.63
4 studies (150 canines) more)
Pocket Probing Depth 1.90 mm 0.18 mm more ◯◯◯◯ very lowc,d Might have deeper pockets
18 studies (563 canines) (0.07 to 0.28
more)
Keratinized gingiva 4.57 mm 0.31 mm less ◯◯◯◯ very lowc,d Might have lower keratinized gingiva width
width (0.01 to 0.61
5 studies (205 canines) more)
Alveolar bone level 1.24 mm 0.51 mm more ⊕◯◯◯ low c
Probably higher alveolar bone loss
6 studies (284 canines) (0.31 to 0.72
more)
Gingival recession 0.23 mm 1.19 mm more ⊕◯◯◯ low c
Little to no difference in gingival recession
7 studies (270 canines) (6.37 less to
8.75 more)

Exposure: various/ Population: children with unilateral upper incisor impaction treated with surgical exposure and orthodontic traction/ Setting: hospitals,
university clinics and private practices (Belgium, Great Britain, Iran, Israel, Italy, Lithuania, Norway, Poland, South Korea, Sweden, Turkey, USA).
CI, confidence interval; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
a
Response in the control group is based on random-effects meta-analysis of the control groups’ risk.
b
Starts from ‘high’
c
Downgraded by two levels for high risk of bias due to methodological issues.
d
Downgraded by one level for inconsistency, as studies were found on both sides of the forest plot.

fact that apart from impacted maxillary central incisors or in periodontal parameters. This is consistent with the find-
canines, also impacted first/second premolars and mandibular ings of a previous quantitative review [45]. In contrast, the
canines were included in the former review. Consistent with original localization of the canine (buccal or palatal) was as-
previous studies [22], the increased PI scores observed could sociated with periodontal outcomes, which may support the
be a result of difficulty maintaining optimal oral hygiene opinion that the degree of alveolar bone thickness around
around the palatal gingival margin of the canine during treat- maxillary canine influences these parameters [51]. Indeed, in
ment, complicated treatment mechanics, or sensitivity around the direct comparisons (Supplementary Table VII) a signifi-
newly established gingival attachment around the impacted cant reduction in bone thickness in the cervical region of the
tooth. aligned maxillary canine was evident.
From a clinical perspective, numerous factors have been The certainty of the available evidence was very low to
proposed to account for periodontal differences between im- low (Table 10), due to high risk of bias and inconsistency.
pacted maxillary incisors and canines that have undergone Of note, reporting biases (small-study effects) were evident
surgical exposure with orthodontic traction. These factors in- for PPD, which, even though they did not affect the results
clude the level of patient oral hygiene during treatment [22], of the present study, could be further compounded by the
excessive bone loss during the surgical exposure procedure lack of reporting of internal and external validity of the peri-
[32, 47, 48], open surgical exposure resulting in ‘bunching’ odontal measurements as assessor measurement reliability
of the mucosa during traction and reduced crown height (intra and inter-assessor) was infrequently assessed robustly.
[49], severity of canine impaction [50], reduced thickness Furthermore, the majority of studies had a small sample size,
of labial bone found with labially impacted teeth [51] and a and most precise studies showed different results than the
higher vertical position of canines [20]. Orthodontic mech- least precise studies indicating a small study effect which can
anics employed during alignment have also been suggested introduce bias and affect the precision of the estimates [52].
to affect periodontal outcomes. Incomplete uprighting of the This is consistent with the findings of wider assessment of
impacted palatal canine has been proposed to result in the oral health reviews in which for all outcomes, nearly 90%
gingival attachment being located more apically and resulting were rated as very low to low with risk of bias and impreci-
in increased PPD [22]. Conversely, root torque applied to im- sion being common reasons for downgrading [53].
pacted canines may decrease bone support or increase root
resorption [48]. Commonly, attachments are bonded on the
palatal aspect of canines during a closed exposure. During Strengths and limitations
traction, rotation of the crown occurs which then requires In contrast to previous reviews [27, 28, 44, 46], a specific pri-
de-rotation. The process of de-rotation is suggested to re- mary outcome was pre-defined in the review’s protocol, which
sult in reduced attached gingivae on the buccal aspect and was registered to improve transparency [54]. To optimize art-
increased length of the clinical crown [25, 49]. Despite these icle yield, the search strategy was developed and performed
anecdotal claims, it is interesting to note that in the subgroup with the assistance of a healthcare librarian [55]. To reduce
analysis, the type of surgical technique for impacted maxillary potential bias, no language restrictions were imposed and
canines (open or closed) was not associated with differences the grey literature was searched. Concerns have been raised
J. Seehra et al. 595

regarding the consistency of risk of bias judgements under- Implications of the results for practice, policy, and
taken as part of study quality assessments [56, 57]. To re- future research
duce this, it has been recommended that the rationale for bias Based on the results of low-quality studies, the reported es-
judgments of primary studies should be described [58]. On timates suggest there is a degree of periodontal compromise
this basis, for all included studies the rationale for bias judge- incurred during the alignment of impacted maxillary incisors
ments has been provided (Supplementary Tables V and VI). and canines following surgical exposure and orthodontic
Selective reporting bias in oral health systematic reviews, has traction. Furthermore, the overall certainty of the available

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been attributed to discrepancies between the final review and evidence as per GRADE recommendations was rated at very
protocol [59]. To account for this bias, all post-hoc protocol low to low with downgrading of the evidence due to high risk
changes have been reported (Supplementary Table II). of bias as a result of methodological issues.
To manage variations in different periodontal measure- The need for further high-quality studies accounting for
ments reported between studies (i.e. individual sides such as bias and confounders has been highlighted [28]. A priori
mesial, distal, etc., per tooth or average values), a decision protocol should be used, stating a clear eligibility criterion,
was undertaken to convert multiple side measurements into the type of surgical procedure, the site of orthodontic at-
a single average value. A limitation of this approach is under- tachment placement, the timing of orthodontic traction, spe-
estimation of the reported estimates. However, individual side cific timepoint measurements of clearly defined periodontal
measurements per tooth have also been included and reported parameters, assessment of assessor reliability, and methods to
secondarily for transparency reasons. To enhance the applic- ensure masking of assessors.
ability and generalizability of the results, studies undertaken Primary studies commonly conclude that the reported dif-
in multiple clinical setting (hospitals, university clinics, or ferences in periodontal outcomes between aligned maxillary
practices) were included. incisor and canine teeth are ‘clinically acceptable’. However,
Another limitation of this review is that the majority of in- it is unclear who is it clinically acceptable to clinicians or pa-
cluded studies were of low methodological quality / internal tients? This general statement is also undermined by the fact
validity. Studies were retrospective and observational in nature, that often 95% CI are not routinely reported with P-values
and therefore subject to methodological biases [60]. Further hence preventing any gauging of clinical significance [64].
limitations of existing studies include small sample sizes with Due to the modest periodontal effects reported, it is unclear if
infrequent priori sample size calculations, unclear reporting of an average patient would detect these. In contrast, laypeople
patient selection, lack of appropriate control groups, and lack of have been reported to be aware of gingival margin discrep-
pre-defined outcomes. These factors precluded the calculations ancies present on the anterior upper teeth [65]. This outcome
of treatment outcome estimates for impacted central incisors. maybe more relevant and pertinent to patients who undergo
The design of observational studies was typically retro- treatment for impacted teeth. Based on the findings of this re-
spective and single cohort, with the spontaneously erupted view, as part of an on-going two arm randomized clinical trial
contralateral tooth serving as the control. Some study au- (ISRCTN12709966), the iMAC Trial [66], a priori secondary
thors described this as a split-mouth design; however, this outcome is to assess gingival aesthetics following the eruption
assumption is incorrect because there is no baseline equiva- (orthodontic space opening alone versus orthodontic space
lence between opposite sides. It can be debated if the spon- opening with immediate traction) of impacted maxillary cen-
taneously erupted contralateral tooth is indeed acting as an tral incisors due to the presence of a supernumerary tooth.
‘untreated control’ group because usually it would be in-
cluded or bonded to as part of fixed appliance therapy to
align the impacted tooth. It has been reported that routine Conclusions
orthodontic treatment can result in increased pocket depth Limited evidence suggests that surgical exposure and ortho-
by 0.23 mm [61]. Although this may appear minimal, when dontic alignment of impacted maxillary central incisor
comparing periodontal outcomes of aligned impacted teeth or canine teeth, results in modest adverse effects in the
versus the ‘untreated controls’, a degree of over- or underesti- periodontium, in terms of CAL, PPD, and bone loss com-
mation in the reported results can occur. At the level of the pared to contralateral normally erupted teeth. However,
primary study, assessment bias could also occur as a result of these findings should be viewed with caution as our certainty
comparing a tooth which has reached periodontal maturation for these outcomes is very low to low due to the bias and het-
(spontaneously erupted) against an impacted tooth whose erogeneity. Further well-conducted studies that transparently
gingival tissues are immature (forced eruption phenomenon) report both objective and patient centred outcomes could be
[15, 48]. Furthermore, in the majority of studies masking useful.
of the assessors who undertook the periodontal measure-
ments was unclear [28]. Based on the study limitations, study
quality was downgraded on the basis of representativeness, Acknowledgments
comparability and duration of outcome. Incomplete reporting The authors wish to thank Helen Nield (Head of Library and
of the included studies precluded an assessment of preplanned Knowledge Services, British Dental Association) for her as-
subgroup and meta-regression analyses and identification of sistance and guidance with the search term strategy.
variables associated with the outcome of interest. As part of
a clinical trial methodology, reporting of patient centred out-
comes has been encouraged [62]. However, as reported in the
Author Contributions
wider dental literature [63], these outcomes including adverse Jadbinder Seehra (Conceptualization-Equal, Data curation-
events were often not reported in the studies included in this Equal, Formal analysis-Equal, Investigation-Equal,
review. The need for more robust studies reporting outcomes Methodology-Equal, Project administration-Equal, Writing
relevant to patients is required. – original draft-Equal, Writing – review & editing-Equal),
596 European Journal of Orthodontics, 2023

Aminah alshammari (Data curation-Equal, Investigation- 7. Becker A, Kohavi D, Zilberman Y. Periodontal status following
Equal, Writing – original draft-Equal, Writing – review the alignment of palatally impacted canine teeth. Am J Orthod.
& editing-Equal), Fidaa wazwaz (Data curation-Equal, 1983;84:332–6. https://doi.org/10.1016/s0002-9416(83)90349-4
Investigation-Equal, Writing – original draft-Equal, 8. Lang NP, Löe H. The relationship between the width of keratinized
gingiva and gingival health. J Periodontol 1972;43:623–7. https://
Writing – review & editing-Equal), Spyridon Papageorgiou
doi.org/10.1902/jop.1972.43.10.623
(Conceptualization-Equal, Data curation-Equal, Formal 9. Miyasato M, Crigger M, Egelberg J. Gingival condition in areas
analysis-Equal, Investigation-Equal, Methodology-

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of minimal and appreciable width of keratinized gingiva. J Clin
Equal, Writing – original draft-Equal, Writing – review & Periodontol 1977;4:200–9. https://doi.org/10.1111/j.1600-
editing-Equal), Tim Newton (Methodology-Equal, Project 051x.1977.tb02273.x
administration-Equal, Supervision-Equal, Writing-orginal 10. Ericsson I, Lindhe J. Recession in sites with inadequate width of
draft-Equal, Writing-review & editing-Equal), Martyn the keratinized gingiva. An experimental study in the dog. J Clin
Cobourne (Conceptualization-Equal, Data curation- Periodontol 1984;11:95–103. https://doi.org/10.1111/j.1600-
Equal, Formal analysis-Equal, Methodology-Equal, Project 051x.1984.tb00837.x
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051x.1976.tb00040.x
12. Crescini A, Nieri M, Buti J et al. Short- and long-term periodontal
Funding evaluation of impacted canines treated with a closed surgical-
There are no financial or non-financial supports to declare. orthodontic approach. J Clin Periodontol 2007;34:232–42. https://
doi.org/10.1111/j.1600-051X.2006.01042.x
13. Hansson C, Linder-Aronson S. Gingival status after orthodontic
Ethical approval treatment of impacted upper canines. Trans Eur Orthod Soc
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