Original Article

Periodontal status of ectopic canines after orthodontic treatment

Ayşegül Dalkılıç Evrena; Şirin Nevzatoğlub; Tülin Arunc; Ahu Acard

ABSTRACT
Objective: To evaluate the periodontal health and tooth vitality of palatally impacted and buccal
ectopic maxillary canines after completion of orthodontic treatment.
Materials and Methods: Fifteen patients who had unilateral, palatally impacted canines and 15
patients who had unilateral, buccal ectopic canines comprised the subjects of the study. Clinical
and radiographic data was collected by recalling the patients in both groups after a mean period of
3.82 6 1.54 years following completion of their orthodontic treatment. In both groups, the
contralateral, normally placed canines served as controls.
Results: Palatally impacted canines had greater pocket depths, higher gingival levels, higher
electric pulp testing scores, and reduced bone levels compared to their contralaterals. Buccal
ectopic canines had increased plaque and gingival bleeding index, greater pocket depths, reduced
attached gingival width, higher gingival levels, increased clinical crown lengths, and higher electric
pulp testing scores compared to their contralaterals. Buccal ectopic canines had lower electric pulp
testing scores and higher bone levels compared to palatally impacted canines.
Conclusion: All ectopic canines had increased plaque and gingival bleeding index, greater pocket
depths, reduced attached gingival width, higher gingival levels, increased crown lengths, higher
electric pulp testing scores, and reduced bone levels compared to their contralaterals. (Angle
Orthod. 2014;84:18–23.)
KEY WORDS: Periodontal health; Tooth vitality; Long term; Ectopic canines; Palatally impacted
canines

INTRODUCTION the proper access for, the surgical approach and the
proper direction for the application of orthodontic
The prevalence of impacted maxillary canines is
forces.3,4
reported to vary between 0.9% and 2.2%, and in most
The two techniques for surgically exposing and
cases, the impacted canines are ectopically posi-
bringing the palatally impacted canine into occlusion
tioned.1 Eighty-five percent of ectopic canines are
are the open approach (OA) and the closed approach
located palatal to the dental arch.2
(CA). The advantages of the OA include the ortho-
The proper localization of the impacted tooth plays a
dontist’s ability to observe the impacted tooth and have
crucial role in determining the feasibility of, as well as
a continuing access to the impacted tooth as it is
moved to its normal position in the dental arch,5,6 as
a
Private Practice, Malatya, Turkey.
b
Assistant Professor, Department of Orthodontics, Marmara well as faster eruption.5 However, this method is often
University, İstanbul, Turkey. associated with multiple periodontal problems, such as
c
Professor and Former Head of Department of Orthodontics, gingival recession,5,7–9 bone loss,5 decreased width of
Yeditepe University, İstanbul, Turkey. keratinized gingiva,9,10 delayed periodontal healing,11
d
Professor, Department of Orthodontics, Marmara University,
and gingival inflamation.9 Periodontal health may be
İstanbul, Turkey.
Corresponding author: Dr Şirin Nevzatoğlu, Marmara Üni- also compromised when the CA is performed.12,13
versitesi, Diş Hekimliği Fakültesi, Ortodonti AD, Teşvikiye mah. Labial impaction of the maxillary canine is less
Büyükçiftlik sok. No: 6 k.3, 34365, Nişantaşı, Şişli, İstanbul, frequent than palatal impaction and is often caused by
Türkiye insufficient arch length. The canine is often positioned
(e-mail: [email protected])
(e-mail: [email protected]) high in the alveolar bone and erupts through the alveolar
mucosa. When detected early, prevention may be
Accepted: May 2013. Submitted: April 2013.
Published Online: July 11, 2013
achieved by the extraction of the deciduous canine.14
G 2014 by The EH Angle Education and Research Foundation, Earlier methods of uncovering impacted canines
Inc. advocated radical bone removal to expose the crown

Angle Orthodontist, Vol 84, No 1, 2014 18 DOI: 10.2319/041513-290.1

EVALUATION OF PERIODONTAL STATUS OF ECTOPIC CANINES AFTER ORTHODONTIC TREATMENT 19

of the impacted tooth so as to remove all bony obstacles minimal bone removal in the Departments of Dental
and to provide an easier path for tooth movement. Surgery of Marmara and Yeditepe Universities. At-
McDonald and Yap15 evaluated the relationship be- tachments had been bonded to the impacted canines
tween the amount of bone removed during surgical at the time of surgical exposure.
exposure and the subsequent bone loss around the In the second group of patients, who had buccal
impacted tooth. They found that the more bone ectopic maxillary canines, orthodontic treatment for
removed initially, the greater the bone loss after alignment of these teeth was completed by conven-
orthodontic treatment. Kohavi et al.16 concluded that tional orthodontic techniques, with or without the
extensive bone removal that might inadvertently involve extraction of permanent teeth. In two patients from
the cementoenamel junction (CEJ) should be avoided. this group, electro surgery was performed for the
Patients treated with more extensive bone removal had canine exposure.
on average 5.4% less bony support than those patients Patients in both groups were recalled for collection
treated with less extensive bone removal. of the clinical data. The periodontal status of the
Since during the treatment of impacted canines both canines was evaluated clinically and radiographically.
surgical and orthodontic procedures are used, tooth In both groups, the contralateral, normally placed
vitality could be influenced as well.1,17 canines served as control. The study was approved
In our retrospective study we assessed the peri- by the Ethical Committee of the Medical Faculty of
odontal status and tooth vitality of palatally impacted Marmara University, İstanbul, Turkey.
canine cases that were exposed with CA and ectopic
buccal canines that were treated with conventional
Clinical Evaluation
orthodontic techniques, and we compared them with
the contralateral canines that served as control teeth Periodontal examination. The following measure-
and also compared them with each other. By deter- ments of the involved canines were made to evaluate
mining to what extent we had been successful in their periodontal health status:
preserving the periodontal health of our treated ectopic
1) Plaque index (PI): The mesial, distal, buccal, and
canine cases, we will have a chance to evaluate our
palatal surfaces were scored on a scale of 0 to 3,
treatment strategies and consider some modifications
according to the method described by Silness and
if needed.
Löe.18
2) Gingival bleeding index (GBI): The same surfaces
MATERIALS AND METHODS
were scored as for the plaque index on a scale of
In order to be able to include a sufficient number of 0 to 3, according to the method of Löe and
patients in the study groups, we examined the Silness.19
archive files of two separate orthodontic departments 3) Pocket depth (PD): The depths of the mesial,
in İstanbul. Selection criteria were as follows: distal, buccal, and palatal gingival pockets were
presence of unilateral palatally impacted or buccal measured as the distance from the free gingival
ectopic canines at the beginning of the treatment, margin to the bottom of the pocket with a
having received orthodontic treatment with fixed standard periodontal probe.
appliances, active treatment completed at least 4) Attached gingival width (AGW): The width of
6 months ago, good oral hygiene, and no systemic attached gingiva was measured by subtracting
disease. A total of 52 patients who met these criteria the pocket depth from the distance between the
were identified. Thirty of these 52 patients, 15 gingival margin and the mucogingival junction.
patients who had unilateral palatally impacted ca- 5) Gingival level (GL): Gingival level on the buccal
nines and 15 patients who had unilateral buccal and palatal aspects was measured with a divider
ectopic canines at the beginning of their orthodontic from the most apical extent of the CEJ to the most
treatment, agreed to come to the recall appoint- apical extent of the gingival margin.
ments. Twenty-one of them were girls and nine of 6) Crown length (CL): Clinical crown length was
them were boys. Mean age of the patients at the measured as the distance between the canine
beginning of the treatment was 11.43 6 1.45 years. cusp tip and the most apical extent of the gingival
Mean treatment duration was found to be 3.71 6 margin.
1.32 years (3.52 6 1.43 years for buccal, 3.90 6
1.21 years for palatal canines). Mean recall period Electric pulp testing score (EPTS). Tooth vitality was
was 3.82 6 1.54 years. assessed with Parkell Pulp Vitality Tester (Parkell Inc,
In the first group of patients, palatally impacted Edgwood, NY), grading from 1 to 10 (10 being
canines had been exposed with a CA technique with nonvital).

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20 EVREN, NEVZATOĞLU, ARUN, ACAR

Figure 2. Root length.

Figure 1. Bone level.

Radiographic Evaluation controls. To make comparisons between impacted

palatal and buccal ectopic canines, the Mann-Whitney
For measurements of bone level and root resorption, U-test was used for nonparametric data, and Student’s
two periapical radiographs were obtained using a long- t-test was used for parametric data. Level of signifi-
cone paralleling technique. All radiographs were cance was selected as P , .05 for all tests. All
scanned. The measurements on these images were statistical tests were made using SPSS 12.0 software
made using Dental Studio NX 2006 Version 6.0 (SPSS Inc, Chicago, Ill).
software (Nemotec, Madrid, Spain). Bone level was
measured by calipers as the distance from the CEJ to RESULTS
the alveolar crest on both the mesial and distal sides
(Figure 1). Root length was measured as the distance Comparison showed statistically significant differ-
from a line connecting the mesial and distal CEJ to the ences in plaque index and gingival bleeding index
root apex using a ruler (Figure 2). scores, pocket depth, attached gingival width, gingival
level, crown length, EPTS, and bone level.
Reliability of the Method Palatally impacted canines had greater pocket
depths (P , .01), higher gingival levels (P , .01),
In order to determine operator reliability and higher EPTS (P , .01), and reduced bone levels (P ,
reproducibility, all the bone-level and root-length .01) compared to their contralaterals (Table 1).
measurements of 60 teeth were repeated 2 weeks
Buccal ectopic canines had increased plaque index
later by the same observer. Correlation between these
(P , .01), increased gingival bleeding index (P , .01),
two sets of measurements was assessed with Pearson
greater PD (P , .05), reduced attached gingival width
correlation analysis.
(P , .001), higher gingival levels (P , .001), increased
crown lengths (P , .001), and higher EPTS (P , .05)
Statistical Method
compared to their contralaterals. Bone level was
The paired-samples t-test was used to compare reduced as well, but this reduction was not statistically
parametric data (pocket depth, attached gingival width, significant (Table 2).
gingival level, crown length, bone level, and root Buccal ectopic canines had lower EPTS (P , .05)
length), and the Wilcoxon signed rank test was applied and higher bone levels (P , .01) compared to palatally
to compare nonparametric data (plaque index, gingival impacted canines (Table 3).
bleeding index, and electric pulp testing score [EPTS]) The correlation between the first and second
between the ectopic canines and their contralateral measurements, which was done in order to evaluate

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EVALUATION OF PERIODONTAL STATUS OF ECTOPIC CANINES AFTER ORTHODONTIC TREATMENT 21

Table 1. Comparison of the Palatally Impacted Canines and Their Contralateral After Orthodontic Treatmenta
Palatally Impacted (n 5 15) Contralateral (n 5 15) Difference
Variable Mean 6 SD Mean 6 SD Mean 6 SD P
Plaque index 1.17 6 0.70 0.80 6 0.56 0.37 6 0.61 ns
Gingival bleeding index 0.45 6 0.61 0.22 6 0.39 0.23 6 0.45 ns
Pocket depth, mm 1.63 6 0.33 1.25 6 0.51 0.38 6 0.40 **
Attached gingival width, mm 3.20 6 0.86 3.13 6 0.99 0.07 6 0.88 ns
Gingival level, mm 0.97 6 0.79 0.53 6 0.52 0.43 6 0.59 **
Crown length, mm 10.27 6 0.46 9.73 6 1.10 0.53 6 1.06 ns
Electric pulp testing score 6.00 6 1.89 5.27 6 1.83 0.73 6 0.80 **
Bone level, mm 1.51 6 0.18 1.29 6 0.27 0.22 6 0.21 **
Root length, mm 10.63 6 1.02 10.81 6 0.82 20.18 6 0.83 ns
a
SD indicates standard deviation; ns, not significant.
* P , .05; ** P , .01; *** P , .001.

the method error, was established to be high. Findings controls. On the other hand, Crescini et al.21 found
suggest that bone level and root length measurements no attachment loss, no recession, and no significant
are reliable (r 5 1.000; P 5 .01). differences in keratinized tissue width in a follow-up
examination of eight cases with impacted canines
DISCUSSION when compared to the contralateral canines. Vermette
The orthodontic treatment aims at moving the et al.22 observed reduced width of attached gingiva and
corresponding tooth into its correct position in the reduced bone levels of treated buccal ectopic canines
dental arch without causing periodontal problems and compared to their contralaterals. On the other hand,
tooth vitality loss. However, the periodontal condition Tegsjö et al.9 found no significant differences in the
and sensitivity of treated impacted canines were periodontal status between treated impacted canines
reported to be affected by the surgical and orthodontic and the nontreated controls.
procedures used. There are studies6,10,13,16 that have The aim of our study was to assess the periodontal
previously illustrated the potential periodontal prob- status and vitality of the palatally impacted and buccal
lems associated with surgical exposure and orthodon- ectopic canines after orthodontic treatment and com-
tic alignment of ectopic canines. On the other hand, it pare them with the contralateral canines that served as
must be remembered that orthodontic treatment itself control teeth and also compare them with each other.
carries a risk of tooth morbidity.20 In both situations, the In the first group of patients, palatally impacted
role of increased difficulty in maintaining adequate oral canines had been exposed using a CA technique with
hygiene during appliance therapy may be significant. minimal bone removal. It can be said that the
When we look at the previous studies in the periodontal condition of treated impacted canines is
literature, we see that there is conflicting evidence as almost always affected, independent of the surgical or
to how the periodontal condition and vitality of the orthodontic procedures used. However, it seems that
impacted canines were affected by treatment proce- less damaging effects on the periodontium should be
dures. Woloshyn et al.12 observed greater pocket anticipated when using the CA technique.5–9
depths and significantly lower crestal bone height in In the second group of patients, who had buccal
the impacted canines compared to contralateral ectopic maxillary canines, orthodontic treatment for

Table 2. Comparison of the Buccal Ectopic Canines and Their Contralaterals After Orthodontic Treatmenta
Bucally Ectopic (n 5 15) Contralateral (n 5 15) Difference
Variable Mean 6 SD Mean 6 SD Mean 6 SD P
Plaque index 1.38 6 0.28 0.77 6 0.50 0.62 6 0.49 **
Gingival bleeding index 0.70 6 0.44 0.20 6 0.37 0.50 6 0.40 **
Pocket depth, mm 1.63 6 0.19 1.47 6 0.13 0.17 6 0.15 *
Attached gingival width, mm 2.87 6 0.64 3.93 6 0.70 21.07 6 0.26 ***
Gingival level, mm 1.20 6 0.75 0.47 6 0.52 0.73 6 0.50 ***
Crown length, mm 10.40 6 0.83 9.13 6 0.99 1.27 6 0.96 ***
Electric pulp testing score 4.60 6 1.18 3.87 6 0.99 0.73 6 0.46 *
Bone level, mm 1.22 6 0.26 1.15 6 0.27 0.07 6 0.19 ns
Root length, mm 10.78 6 0.90 10.96 6 0.77 20.18 6 0.64 ns
a
SD indicates standard deviation; ns, not significant.
* P , .05; ** P , .01; *** P , .001.

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22 EVREN, NEVZATOĞLU, ARUN, ACAR

Table 3. Comparison of the Buccal Ectopic and Palatally Impacted Canines After Orthodontic Treatmenta
Buccally Ectopic (n 5 15) Palatally Impacted (n 5 15) Difference
Variable Mean 6 SD Mean 6 SD Mean 6 SD P
Plaque index 1.38 6 0.28 1.17 6 0.70 0.22 6 0.75 ns
Gingival bleeding index 0.70 6 0.44 0.45 6 0.61 0.25 6 0.67 ns
Pocket depth, mm 1.63 6 0.19 1.63 6 0.33 0.00 6 0.40 ns
Attached gingival width, mm 2.87 6 0.64 3.20 6 0.86 20,33 6 1.05 ns
Gingival level, mm 1.20 6 0.75 0.97 6 0.79 0.23 6 1.12 ns
Crown length, mm 10.40 6 0.83 10.27 6 0.46 0.13 6 1.06 ns
Electric pulp testing score 4.60 6 1.18 6.00 6 1.89 21.40 6 2.26 *
Bone level, mm 1.22 6 0.26 1.51 6 0.18 20.29 6 0.29 **
Root length, mm 10.78 6 0.90 10.63 6 1.02 0.16 6 1.49 ns
a
SD indicates standard deviation; ns, not significant.
* P , .05; ** P , .01; *** P , .001.

alignment of these teeth was completed by conven- the bone level of the palatally impacted canines after
tional orthodontic techniques. After enough space was treatment may be related to the more extensive bone
created for ectopic canines by the clinician, the teeth removal during the closed flap surgical approach.
erupted spontaneously except in two cases. Since the Another finding of the present study was that although
position of these two canines was coronal to the surgical intervention was performed in only two of the
mucogingival junction, the gingival tissue around the buccal ectopic canines, the mean plaque index and
crowns was removed with electro surgery in order to gingival bleeding index scores, pocket depth and crown
place a bracket; the remainder of the group was level increased compared to their contralaterals. Reduced
treated without any surgical procedure. In the patients attached gingival width with higher gingival levels and
who had electro surgery, no bone was removed higher EPTS were also among the findings in this group.
around the crown. According to Kohavi et al.,10 attached gingival width
In this study, six periodontal parameters were used. was significantly reduced following the alignment of
These were chosen from among the most commonly buccal ectopic maxillary canines, which is in parallel
used periodontal parameters so as to cover all dental with our results. The reasons for this deterioration in
and gingival landmarks. Many of the authors used two, periodontal health could not be elucidated; however,
three, or five of them.1,17,23 we can speculate that it is related to the emergence of
In our study, we measured the bone loss on the buccal ectopic canines through the alveolar
periapical radiographs. In the literature, many of the mucosa and the insufficient buccal bone support.
authors used these films as well, such as Kokich and Comparison of the buccal ectopic and palatally
Mathews,24 Kohavi et al.,16 Woloshyn et al.,12 Hansson impacted canines revealed that buccal ectopic canines
and Rindler,25 and Becker.26 had lower EPTS and higher bone levels compared to
We compared buccal ectopic and palatally impacted palatally impacted canines. The shorter treatment
canines with their contralateral controls. duration of buccal ectopic canines and the fact that
We found that palatally impacted canines had greater there was no need for bone removal during (except in
pocket depth, higher gingival levels, higher EPTS, and two cases) their treatment period might have account-
reduced bone levels compared to their contralaterals. ed for this difference. In the literature there are only a
The results of Burden et al.27 in their study group of 18 few studies about the vitality of impacted maxillary
patients with unilateral palatal impaction of a maxillary canines after active orthodontic treatment. Blair et al.17
canine were greater pocket depth and reduced bone reported on the tooth vitality loss from the treatment of
levels, which are similar to our results. A good gingival palatally impacted maxillary canines. In another study,
and periodontal status with slight differences between D’Amico et al.1 followed up on a total of 61 children
treated and untreated sides was reported by Hansson who had received treatment for impacted maxillary
and Rindler,25 though increased pocket depth and lower canines on average 3.5 years earlier in order to
marginal bone level were registered. evaluate the long-term results of the treatments. As a
Since our study was a retrospective study, it was not result they found that the vital response of two canines
possible to obtain sound information on how much bone was reduced. Thus, both orthodontic and surgical
was removed during the surgical procedure. Of course procedures can influence sensitivity of the treated
the volume of bone removal is a very important variable impacted teeth. In our study, the long treatment
influencing long-term periodontal health. The increases duration, in addition to the orthodontic forces applied
in the pocket depth and gingival level and decrease in to these teeth, might have influenced tooth vitality.

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EVALUATION OF PERIODONTAL STATUS OF ECTOPIC CANINES AFTER ORTHODONTIC TREATMENT 23

The findings of this study should be interpreted with canines—a long term follow-up study of two surgical
caution due to the following limitations: the sample size techniques. Swed Dent J. 1984;8:257–263.
10. Kohavi D, Zilberman Y, Becker A. Periodontal status
was small, and the severity of the ectopia and the following the alignment of buccally ectopic maxillary canine
distance the tooth has to travel until it reaches its final teeth. Am J Orthod. 1984;85:78–82.
place were not taken into account. They both may 11. Becker A, Shpack N, Shteyer A. Attachment bonding to
have an impact on periodontal health. On the other impacted teeth at the time of surgical exposure. Eur J Orthod.
1996;18:457–463.
hand, it would not be wrong to say that the changes
12. Woloshyn H, Årtun J, Kennedy DB, Joondeph DR. Pulpal
observed in the periodontal status and vitality of the and periodontal reactions to orthodontic alignment of
ectopic teeth, though statistically significant, did not palatally impacted canines. Angle Orthod. 1994;64:
reach clinical significance. 257–264.
13. Becker A, Kohavi D, Zilberman Y. Periodontal status
following the alignment of palatally impacted canine teeth.
CONCLUSIONS Am J Orthod. 1983;84:332–336.
N The alterations in the periodontal health of palatally 14. Power SM, Short MB. An investigation into the response of
palatally displaced canines to the removal of deciduous
ectopic canines, compared to their contralaterals, were canines and an assessment of factors contributing to
in the form of alveolar bone loss, increased probing favourable eruption. Br J Orthod. 1993;20:215–223.
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N The periodontal health parameters of buccal ectopic tion of direct traction of unerupted teeth. Am J Orthod. 1986;
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16. Kohavi D, Becker A, Zilberman Y. Surgical exposure,
They had increased plaque index and gingival orthodontic movement, and final tooth position as factors
bleeding index, greater pocket depths, reduced in periodontal breakdown of treated palatally impacted
attached gingival width, higher gingival levels, canines. Am J Orthod. 1984;85:72–77.
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