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Tu nn el t r a c t i on o f n f r aosseous im pacted m ax i l l a r y

can in es. A th r ee year per iodon ta l o l l ow u p

A . C r e s c in i , M D M , C . C l a u s e r , M D M , ~ R . G i o r g e t t i, M D M , P . C o r t e l li n i , M D M , a n d

G . P . P i n i P ra t o , M D M

i e n a

and Firenze, ha l)

A s u r g i ca l o r t h o d o n t ic p r o c e d u r e w a s u s e d t o tr e a t d e e p i n f ra o s s e o u s i m p a c t e d c a n i n e s t e s t t e e t h )

a s s o c i a t e d w i t h t h e p e r s i s t e n c e o f t h e d e c i d u o u s t o o t h in 1 5 p a t ie n t s w h o h a d t h e c o n t r a l a te r a l

c a n i n e n o r m a l l y e r u p t e d c o n t ro l t e e th ) . T h e p e r i o d o n ta l o u t c o m e w a s e v a l u a t e d a t t h e e n d o f t h e

o r t h o d o n t ic t r e a t m e n t a n d 3 y e a r s l a te r . A f te r e x t r a c t io n o f t h e d e c i d u o u s c a n i n e , a m u c o p e r i o s t e a l

f la p w a s r a i s e d o n t h e b u c c a l s e v e n c a s e s ) o r p a l a ta l e i g h t c a s e s ) a s p e c t , to e x p o s e t h e c u s p o f

t h e i m p a c t e d t o o t h . T h e e m p t y s o c k e t o f t h e d e c i d u o u s t o o t h w a s e x t e n d e d t o r e a c h t h e i m p a c t e d

c u s p a n d t o f o r m a n o s s e o u s t u n n e l . A c h a i n w a s p a s s e d t h r o u g h t h e t u n n e l a n d f i x e d t o a b o n d e d

d e v i c e o n t h e i m p a c t e d c u s p . T h e f la p w a s s u t u r e d b a c k i n t o its o r i g in a l p o s i t io n . T h e c h a i n w a s

u s e d f o r t r a c ti o n t o t h e i m p a c t e d c a n i n e t o w a r d t h e c e n t e r o f th e a l v e o l a r r i d g e . N o a t t a c h m e n t l o s s

a n d n o r e c e s s i o n w e r e o b s e r v e d a t t h e e n d o f t h e a c t iv e t h e r a p y o r 3 y e a r s l a t e r. N o s i g n i fi c a n t

d i f fe r e n c e s i n k e r a t in i z e d t i s s u e w i d th w e r e o b s e r v e d b e t w e e n t e s t a n d c o n t r o l t e e t h a t t_ he f o l lo w - u p

exam i na t i on . AM J ORTHO D DI=NTOFACORTHOP 1994 ; 105 : 61 -72 . )

T h e s u r gi c a l o r t ho d o n t i c t r e at m e n t o f i m -

p a c t e d c a n i n e s i s a i m e d a t b r i n g i n g t h e t o o t h i n t o i t s

c o r r e c t p o s i ti o n i n t h e d e n t a l a r c h w i t h o u t c a u s i n g p e r i -

o d o n t a l d a m a g e . T o a c h i e v e t h is g o a l , a v a r i e t y o f

s u r g i c a l a n d o r t h o d o n t i c t 2 '7 t e c h n i q u e s h a v e b e e n

p r o p o s e d b o t h i n r e l a t i o n t o th e p o s i t i o n o f t h e i m p a c t e d

too th a nd to the l iga t ion t echn iqu e u sed . ~ s2~

I n t h e c a s e o f s u b m u c o s a l i m p a c t i o n , m u c o g i n g i v a l

p r o b l e m s m a y a r is e . P e r f o r m i n g a g i n g i v e c t o m y h a s

b e e n p r o p o s e d , z-5 H o w e v e r , i t h a s b e e n s u g g e s t e d 3 a n d

s h o w n t h a t t h e w i n d o w a p p r o a c h i n d i ca t e s t h a t s t a ti s -

t i c a l ly s i g n i f i ca n t l o s s o f a t t a c h m e n t , r e c e s s i o n a n d g i n -

g i v a l i n f l a m m a t i o n o c c u r o n m a x i l l a r y c a n i n e s a f t e r

s u r g i c a l e x p o s u r e . ' 9 T h e r e f o r e a p a r t o f t h e k e r a t i n i z e d

g i n g i v a m u s t b e p r e s e r v e d 9 o r a n a p i c a l l y p o s i t i o n e d

f lap sho uld be used . 3 6.9T h i s a p p r o a c h a i m s a t o b t a i n in g

k e r a t i n i z e d g i n g i v a a r o u n d t h e e n t i r e e ru p t i n g m a x i l l a r y

c a n i n e . 7 R e g a r d l e s s o f t h e t e c h n i q u e u s e d , t h e t o o t h i s

l e f t e x p o s e d a f t e r h a v i n g p o s i t i o n e d t h e a t t a c h i n g d e v i c e

t o t h e c r o w n .

I n t h e c a s e o f d e e p i n f r a o s s e o u s i m p a c t i o n , t h e s e

t e c h n i q u e s c a n n o t a l w a y s b e u s e d s a f e l y a n d o t h e r s t e p s

a r e r e q u i r e d t o a c h i e v e a s a t i s f a c t o r y p e r i o d o n t a l o u t -

c o m e . F u l l t h i c k n e s s f l a p s m u s t b e r e f l e c t e d t o a d e -

q u a t e l y a c c e s s t h e c r o w n o f t h e i m p a c t e d t o o t h . L ~ '

L e a v i n g t h e c r o w n e x p o s e d e n t a i l s b o n e r e s e c t i o n a n d

d i s p l a c e m e n t s o f t h e s o f t t i s s u e s . I n e a c h c a s e s , a l -

'Denta l S chool , Unive r s i ty of S iena , S iena , I ta ly .

bAccademia Toscana d i R ice rea Odontos toma to log ica , F i r enze , I ta ly .

Copyr igh t 9 1994 by the Amer ican Assoc ia t ion of Or thodont is t s .

0889-5406194151.00 + 0.1 0 8/1/31~f~02

t h o u g h t h e r e m o v a l o f a s i g n i fi c a n t p o r t io n o f c o rt i c a l

b o n e f a v o r s e r u p t i o n o f t h e t o o t h , r e m o v i n g t i s s u e m a y

r esu l t in the los s o f bone supp or t . ' ~ S a t i s f ac to r y r e su l t s

c o u l d b e e x p e c t e d i f t h e p h y s i o l o g i c e r u p t io n p a t t e rn i s

r e s t o re d . W h e n a p e r m a n e n t t o o t h e ru p t s id e a l l y it w i l l

b r e a k t h r o u g h t h e g i n g i v a n e a r t h e c r e st o f t h e r id g e s o

t h a t s o m e g i n g i v a w i l l b e p r e s e n t o n t h e f a -

c i a l . . , s u r fa c e . ' z ' O n t h e c o n t ra r y , W h e n m u c o g i n -

g i v a l i n a d e q u a c y e x i s t s , r e c e s s i o n w i t h r o o t e x p o s u r e

m a y f o l l o w . 'z '

S e v e r a l s t u d i e s h a v e b e e n p u b l i s h e d o n t h e p e r i -

o d o n t a l s t a t u s o f i m p a c t e d c a n i n e s a f t e r s u r g i c a l o r th o -

dont ic r epos i t ion ing . 4 ''~ L i t t l e da ta a r e ava i lab le9.'9

o n t h e p e r i o d o n t a l s t a t u s f r o m s a m p l e s i n c l u d i n g o n l y

d e e p i n f r a o s s e o u s i m p a c t i o n s , w h e r e t h e p r o p o s e d s u r -

g i c a l o r t h o d o n t i c t e c h n i q u e s a r e h a r d l y a p p l i c a b l e a n d

t h e p r o g n o s i s f o r c o r r e c t i o n m a y b e g u a r d e d 3 7

T h i s a r t i c l e d e s c r i b e s a s u r g i c a l a p p r o a c h f o r t h e

o r t h o d o n t i c t r e a t m e n t o f d e e p i n f r a o s s e o u s im p a c t e d

c a n i n e s . T h i s t e c h n i q u e a l l o w s f o r o r th o d o n t i c t r a c t i o n

o f t h e i m p a c t e d t o o t h t o t h e c e n t e r o f t h e a l v e o l a r r i d g e .

T h e p e r i o d o n t a l o u t c o m e o f th e s e c a s e s w a s e v a l u a te d

a f t e r a 3 - y e a r f o l l o w - u p p e r i o d .

M ATERI ALS AND M ETHODS

The material for this study includes the records of 15

patients, w ho were treated from January 1984 to July 1987

and follow ed po stoperatively for 3 years. T hey ,.,,'ere all con-

secutive patients who me t the entry criteria. A ges ranged from

13 years and 2 months to 17 ycars and I month, with an

averag e age of 14 years and 8 months (standard deviation: l

6

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C r e s c i n i e t a l . merican Journal o f Orthodontics and Dentofacial Orthopedics

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E D C

Fig. 1. Sch em atic drawing i l lustrates cri ter ia used to define deep infraosseous impaction. Th e tracings

are ma de on p anoram ic rad iographs. The mid l ine A ) ; the occlusal plane (from the f i rst m olar to the

incisal edg e of ce ntral incisor ) B ) ; the long axe s of the central incisor, of the lateral incisor, o f the f i rst

bicuspid, and of th e impacted canine respectively C ) , D ) , E ) , and F ) ; the ang le between F and A

(~); the distance be tween the cusp of the impacted c anine and the occlusal plan e B ) d ) ; the sectors

where the cusp o f the impacted can ine can be located

1 ) , 2 ) ,

and

3 ) .

T a b l e I. L o c a t i o n o f t h e i m p a c t e d t e e t h , b a s e d

o n t h e c r i t e r i a il l u s t r a t e d i n F i g . 1

C as e num ber l S l c t l d

3 43 22

2 3 48 21

3 3 45 17

4 3 57 22

5 2 51 24

6 3 44 20

7 2 49 19

8 2 50 18

9 1 46 22

10 3 56 21

It 3 42 22

12 1 44 20

13 3 58 23

14 2 42 21

I5 2 43 19

S, Num ber of the sector (1 to 3), where the medial position of the

crown of the impacted canine is located.

a, Ang le between the long axis of the impacted canine and the

midline.

d, D istance between the cusp of the impacted c anine and the occlusal

plane, in mm.

y e a r a n d 0 . 6 m o n t h s ) . E l e v e n o f t h e p a ti e n ts w e r e g i r l s a nd

f o u r w e r e b o y s .

S e l e c t i o n c r i t e r i a i n c l u d e d t h e f o l l o w i n g :

1 . U n i l a t e ra l i m p a c t i o n o f t h e m a x i l l a r y c a n i n e : T e n o f

t h e t e e t h w e r e o n t h e r i g h t s i d e w h e r e a s f i v e w e r e o n

t h e l e f t . T h e s p o n t a n e o u s l y e r u p t e d c a n i n e s o n t h e

o p p o s i t e s i d e s s e r v e d a s c o n t r o l t e e t h .

2 . A v a i l a b i l i t y o f p e r i o d o n t a l c h a r t i n g s r e c o r d e d a t t h e

e n d o f t h e o r t h o d o n t i c t r e a t m e n t , a s w e l l a s 3 y e a r s

a f t e r t r e a t m e n t .

3 . P r e s e n c e o f th e d e c i d u o u s c a n i n e c o rr e s p o n d i n g t o th e

i m p a c t e d t o o t h i n t h e d e n t a l a r c h . I f t h e d e c i d u o u s

t o o t h h a d e x f o l i a t e d , t h e c a s e w a s e x c l u d e d f r o m t h is

s tudy .

4 . F u l l y f o r m e d a p e x o f t h e r o o t o f t h e i m p a c t e d c a n i n e .

E a r l i e r c a s e s w e r e d i s c a r d ed .

5 . D e e p i n f r a o s s eo u s l o c a t i o n o f t h e i m p a c t e d c a n i n e .

T h e l o c a t i o n o f t h e i m p a c t e d c a n i n e w a s a s s e s se d o n

t h e p a n o r a m i c i m a g e ( S i e m e n s o r t h o p a n t o m o g r a p h

n a n o d o r 2 P , S i e m e n s C o r p . , I s e l i n , N . J . ) , b y u s i n g a

m o d i f i e d v e r s i o n o f t h e c r i t e r ia p r o p o s e d b y E r i c s o n

a n d K u r o l - 8 ( F i g . 1 ): ( 1 ) t h e m o s t m e d i a l p o s i t i o n o f

t h e c r o w n w a s i d e n ti f i ed i n o n e o f t h r e e s e c t or s ( S ) ;

c a s e s w h e r e t h e p o s i t i o n o f t h e c u s p w a s d i s t a l t o t h e

f i r s t p r e m o l a r a x i s o r w h e r e i t c r o s s e d t h e m i d l i n e

w e r e d i s c a r d e d ; ( 2 ) t h e i n c l i n a t i o n a ) o f t h e m a x i l l a r y

c a n i n e w a s m e a s u r e d i n r e l a t i o n t o t h e m i d I i n e ; c a s e s

w i t h c t < 4 0 ~ w e r e d i s c a r d e d ; a n d ( 3 ) t h e d i s t a n c e d )

b e t w e e n t h e c u s p o f t h e c a n in e a n d t h e o c c l u s a l p l a n e

w a s m e a s u r e d i n m m ; c as e s w i t h d < 1 5 m m w e r e

d i s c a r d e d .

T h e d a t a r e l a t i v e t o t h e l o c a t io n o f e a c h c a n i n e a r e s u m -

m a r i z e d i n T a b l e I . C a s e s o f s u b m u c o s a l i m p a c t i o n w e r e

d i s c a r d e d .

A l l t h e r e c o r d s m e e t i n g t h e a b o v e e n t r y c r i t e r i a w e r e

i n c l u d e d i n t h e s t u d y .

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olume

105 No. I

C : ; : -

f ~ ' ' - - -L , L . t r %.. ; :._1.~_P~=,, -. ,

J

C

Fig. 2. a Right maxillary deciduous canine is still in place b A full thickness flap is reflected and the

deciduous ca nine is extracted. C Cortical bone has be en resected to exp ose the crown of the impacted

tooth d Bone is drilled at the bottom of the socket of the deciduous can ine to obtain a complete

osseous tunnel.

b

O r t h o d o n t i c treatment

The dura t ion of o r thodontic t r ea tment inc luded the en t i r e

per iod of ac t ive therapy , thus exc luding the per iod of r e ten t ion

in which a Hawley ' s p la te was worn for an average of 11

months .

The to ta l durat ion of the t r ea tment w as d iv ided in to th ree

phases (Table 11).

Phase 1: The a ssociated or thodon ti c problem s w ere at-

tended to and suff icient space was made in the dental arch

for the impac ted can ine .

Phase 2 : Trac t ion was per formed on the impac ted too th .

The dura t ion o f th is phase was ca lcu la ted as the t ime e lapsed

be tween the appl ica t ion o f the t r ac t ion device and the e rupt ion

of the cusp of the impac ted can ine .

Phase 3 : The can ine was comple te ly a l igned with in the

dental arch.

Dur ing the or thodontic t r ea tment , pa t ien ts were reca l led

month ly to ad just the ir appl iances and re inforce ora l hygiene

measures . Reca l ls were made every 6 months th rough the 3-

year fo l low-up phase .

Surgical procedure

Given the deep inf raosseous pos i t ion of the impac ted

canines, a full thickness mucoperiosteal f lap had to be

T a b l e II. D u r a t i o n o f t h e o r t h o d o n t i c t r e a t m e n t

a n d f o l l o w - u p p e r i o d , e x p r e s s e d i n m o n t h s

Total duration 18 32 22 3.75

Phase 1 3 12 5 2.37

Phase 2 8 13 11 1.4 7

Phase 3 4 11 6 1.85

Follow-up 36 41 39 1.61

Min Minimum; Mar. maximum.

raised. L2 The tech niques u sed both in the cases of buccal

and pa la ta l access were equa tab le . The choice of the one or

the o ther access approach was based on the re la t ionsh ip of

the c rown of the impac ted can ine to the apexes of the

incis ors. :9

Seven of the 15 cases were treated through buccal access

(Fig . 2) . A full thickness f lap was raised to expo se the cortical

p la te , and the dec iduous can ine was removed (Fig . 2 , b ) .

Cor t ica l bone was removed to provide access to the c rown,

and the fo l l icu la r socke t was e l imina ted (Fig . 2 , c ) . A low-

speed bur was inse r ted in to the seat o f the dec iduous too th ' s

root to dr ill a perforation into the hone under careful coolir lg,

to r each the c rown of the impac ted can ine (Fig . 2 , d ) . The

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Fig. 3 . Han dma de chains fixed to different attachment devices: a, fine mesh; b, bo nded bracket base

with a soldered ring; and c, button.

Fig. 4. a, C hain is passed through osseous tunnel and fixed to impacted canine by me an sof a b onded

button, b, The flap is repositioned and sutured. The chain emerges from the empty socket of the

deciduous canine.

perforation and the deciduous socket f ormed a tunne l that was

used for the t rac t ion . A handmade wire cha in of r ings ap-

proximate ly 1 .5 m m in d iameter was prepared wi th 0 .01 l -

inch ligature wire (Fig. 3). The chain was passed through the

osseous tunnel and fixed as closely as possible to the cusp of

the impac ted canine by means of an a t taching device (Fig .

4 , a ) , which , depend ing on the case , was e i ther a bonded

button, a bonded bracket base with a soldered ring on it , or

an ana tomica l ly contou red f ine mesh (Fig . 3) . The bon ding

was tested by a 150 gm appl ied wi th a dynamometer . The

flap was then repositioned and sutured in its original seat.

The cha in passed through the bone tunne l and emerged from

the socket of the deciduous tooth (Fig. 4, b). One week after

surgery, the sutures were removed and the traction phase

began. A force of approximately 100 gm was applied while

care was taken to mai ntain the chain at the center of the socket.

The elastic traction was directed to the center of the alveolar

ridge; a palatal traction force was thus applied.

Eight cases were treated by using the same procedure,

though through a palatal flap (Fig. 5). In these cases, the

elastic traction was directed buccally.

During the or thodont ic t rac tion phase , the e rupt ion of the

impacted tooth was guided through the tunnel, between the

internal and external cortical plates. The cusp o f the impacted

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t lL

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Fig. 5. Sa me procedure can be carried out on pala tal side. a Th e full-thickness flap is raised; b the

crown is expos ed; c the tunnel is completed; d the chain is attached and passed through the tunnel.

Fig. 6. Impacted canine erupts at center of alveolar ridge.

canine thus emerged a t the cente r of the a lveola r process ,

r ep lac ing the dec iduous canine in an a rea sur rounded by ker -

a t in ized g ingiva Fig . 6 ) .

Figs. 7 to 10 illustrate case no. 13.

eriodontal evaluation

All of the presented cases underwent two per iodonta l

eva lua t ions : one a t the end of ac t ive t r ea tment base l ine) and

another a f te r an avcrage per iod of 39 months fo l low-up)

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" 1 1 I L - , w .

Fig. 7. Case no. 13 14-year- and 4-month-old girl. a Clinical view : the deciduo us max illary right canin e

is still in the arch whil e the perma nent left cani ne has normal ly erupted b and c Pretreatment

radiographic vie ws of the sam e case: dee p infraosseous impaction o f the maxil lary right canine.

Fig. 8. Ca se no. 13. a During surgery: the chain is attached and passes through the osseous tunnel.

b Rad iograp hic ma ge. r and d Buccal and occlusal views during orthodontics: note that the traction

is directed tow ard the center of the a lveolar ridge.

(Table l l). Examinations and chart ings were always m ade by

the same examiner, lntrarater rel iabil i ty was tested, repeating

three complete exam inations at baseline and follow-up: 91

agreement in measurements was assessed.

The following periodontal parameters were evaluated on

both the treated (test) and the spontaneously erupted (control)

teeth at baselin e and follow -up visits: (I) plaque index (PII)~~

(2) bleed ing inde x ~' (bleed ing after gentle p robing); (3) pr ob-

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Fig. 9. Final clinical a) and radiographic b and e) appe aran ce of same case no. 13.

F

t

9 4' |

I

Fig. 10. Case no. 13. a, Occlusal view at the end of treatment, b, Buccal view of the treated canine.

Note the normal appearance of the gingiva.

b

ing pocke t dep th : measured as the d is tance be tween the f ree

g ingiva l marg in and the bo t tom of the c l in ica l pocke t ( rounded

to the nearest ha lf mil l imete r ) with a Wi l l iam s Of f se t pe r i -

odonta l p robe . The measurements were made a t s ix s i tes on

each can ine : the mes iobucea l , midbucca l , d is tobucca l , d is -

to l ingua l , mid l ingua l , and mes io l ingua l ; (4 ) c l in ica l a t tach-

ment leve l : the d is tance f rom the cementoenamel junc t ion

(CEI) to the bo t tom of the c l in ica l pocke t , rounded to the

neares t ha lf mil l imete r . The measurements were made a t the

same sites as the pocket depth measurements; and (5) width

of kera t in ized t is sue , f rom the g ing iva l marg in to the mu-

cogingiva l junc t ion .

S t a t i s t i c a l

analysis

Descr ip t ive s ta t is t ics were computed to summar ize the

da ta r e la t ive to age , dura t ion of the or thodontic t r ea tment ,

and dura t ion of the fo l low-up .

Quant i ta t ive tes t and contro l pe r iodonta l measurements

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merican Journal o f Orthodontics and Dentofacial Orthopedics

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994

a b l e Ill. Baseline average values and standard deviations of quantitative periodontal parameters.

Attach ment loss is not reported as its value was consi stently 0

est side Con trol side Differences

AVG I SD AVG I SD AVG I SD t

PD I 2.27 0.37 2 0.27 0.27 0.53 1.948

PD2 1.77 0.59 1.4 0.33 0.37 0.58 2.442*

PD3 2.5 0.42 2.03 0.30 0.47 0.51 3.5 *

PD4 2.17 0.36 2.03 0.4 0.13 0.48 1.075

PD5 1.87 0.44 1.77 0.5 0.1 0.43 0.899

PD6 2.27 0.46 2.03 0.48 0.23 0.37 2.432*

KT 5.13 1.37 4.5 0.82 0.63 0.97 2.522*

These values are expressed in millimetersand rounded o the second decimal digit. The roundingoff results in occasional discrepanciesbetween

the average difference and the difference between averages (see PD4 and PD6).

Test side

Experimental(impaction)side.

Control side

Control (spontaneouseruption) side.

Differences

Differencebetween test and control sides.

AVG

Average;

SD

standard deviation;

PD

pocket depth.

I = Mesiobuccal;2 = midbuccal;3 = distobuccal;4 = mesiopalatal;5 = midpalatal;6 = distopalatal.

hT

Keratinized issue width.

*Significant at the 0.05 level (P < 0.05).

**Significant at the 0.01 level (P < 0.01).

Statistical significancedoes not imply clinical significance.

(probing pocket depth and attachment level at each site; ker-

atinized tissue width on each tooth) were compared by means

of Student 's t test, choosing a significance level a = 0.05.

The same test was used to compare means from teeth that

were treated by palatal or buccal surgical access and to com-

pare means of baseline and follow-up data.

Frequency distributions of qualitative variables (plaque

index, bleeding index) were assessed.

A separate analysis was carried out to compare the effects

of palatal and buccal access approaches: the differences be-

tween test and control sides at baseline (end of the treatment)

in palatal cases were compared with the same differences in

the buccal cases. Pooling of the data was planned if the

separate analysis showed no significant differences between

the two categories (buccal and palatal).

R E S U L T S

The postoperative period was apparently uneventful

in all of the cases. All the 15 impacted canines were

successfully moved into the arch and aligned. No case

of ankylosis was observed in this sample. The attaching

device was never lost. No rebound of the delivered

canines from the occlusal plane was observed at the

follow-up examination. The duration of the overall

orthodontic treatmen t and of each individua l phase are

reported in Table II. The comparison between cases

treated by palatal and buccal access showed no signif-

icant difference in patients' age nor in the duration of

each treatment phase.

B a s e l i n e v i s i t a t th e e n d o f t h e a c t iv e

o r t h o d o n t i c t r e a tm e n t )

The separate analysis did not show any significant

difference in the periodontal parameters between cases

treated by palatal or buccal access. The data were thus

pooled for further analysis.

Plaque was detected (PII = 1) in only three cases,

on both test and control sides. Bleeding after probing

was found in five cases on the test side and in two of

these five cases on the control side.

Pocket depth measurements are summarized in

Table III. The max imum observed value was 3 mm on

both test and control sides. The minimum value was

0.5 mm on the test side and 1 mm on the control side.

The average probing pocket depths were significantly

greater in three sites, but the single differences betwe en

the sides were incons istent and never exceeded 1 mm.

Clinical attachment loss and recession were not ob-

served in any of the cases.

The width of keratinized tissue (Table III) ranged

from 2.5 to 7.5 mm on the test side and from 3 to

6 mm on the control side. The average difference be-

tween test and control sides was statistically significant,

but clinically negligi ble (0.63 mm) . Mo reover, the dif-

ferences were not consistent, ranging from tissue 2 mm

wider on the test side to 1.5 mm wider on the control

side.

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Volume 105, No 1

T a b l e I V . F o l l o w - u p a v e r a g e v a l u e s a n d s t a n d a r d d e v i a t io n s o f q u a n t i t a t iv e p e r i o d o n t a l p a r a m e t e r s .

A t t a c h m e n t l o s s i s n o t r e p o r t e d a s i t s v a l u e w a s c o n s i s t e n t l y 0

I Test side

A V G I S D

Contro l s ide

A V G I S D

Differences

S D

PD I 1.93 0.53 1.67 0.36 0.27 0.65 1.586

PD2 1.03 0.30 1.23 0.26 - 0.2 0.32 2.449

PD3 1.83 0.31 1.87 0.35 - 0.03 0.30 0.435

PD4 1.90 0.39 1.77 0.37 0.13 0.44 1.167

PD5 1.47 0.35 1.43 0.37 0.03 0.35 0.367

PD6 1.90 0.47 1.83 0.49 0.07 0.42 0.619

KT 3.9 0.89 3.97 0.67 - 0.07 0.59 0.435

Abbreviations as in Table III.

F o l l o w - u p v i s i t 3 y e a r s a f t e r t h e e n d o f t h e

o r t h o d o n t i c t r e a tm e n t )

P l a q u e w a s d e t e c t e d

i n

f i v e e x p e r i m e n t a l s i t e s a n d

i n

f o u r o f t h e c o r r e s p o n d i n g c o n t r o l s i t e s . B l e e d i n g a f t e r

p r o b i n g w a s o b s e r v e d i n t h r e e s i t e s o n b o t h t e s t a n d

cont ro l s ides .

P o c k e t d e p t h m e a s u r e m e n t s a r e s u m m a r i z e d i n

T a b l e IV . T h e p o c k e t d e p t h r a n g e d f r o m 0 . 5 t o 3 m m

o n t h e t e s t s i d e a n d f r o m 1 t o 3 m m o n t h e c o n t r o l s i d e .

I t w a s s i g n i f ic a n t l y l e s s o n t h e t e s t s i d e a t t h e m i d b u c c a l

s i t e o n l y . D i f f e r e n c e s w e r e n o t s i g n i f i c a n t a t t h e o t h e r

s i tes .

N o c a s e o f r e c e s s i o n o r a t t a c h m e n t l o s s w a s o b -

s e r v e d .

T h e k e r a t i n i z e d t is s u e w i d t h ( T a b l e I V ) r a n g e d f r o m

2 t o 5 m m o n t h e t e s t s i d e a n d f r o m 3 t o 5 m m o n t h e

c o n t r o l s i d e . T h e d i f f e r e n c e b e t w e e n t h e t w o s i d e s w e r e

not s ign i f i can t .

D i f f e r e n c e s b e t w e e n b a s e l i n e a n d

f o l l o w - u p m e a s u r e m e n t s

T h e a v e r a g e p o c k e t d e p t h d e c r e a s e d o n b o t h t e s t

and con t ro l s ides (Tab le V) . A pa ra l l e l s ign i f i can t re -

d u c t i o n i n t h e w i d t h o f k e r a t i n i z e d t is s u e w a s o b s e r v e d

o n b o t h s i d e s ( T a b l e V ) . T h e r e d u c t i o n i n p o c k e t d e p t h

a n d k e r a t i n i z e d t i ss u e w a s m o r e p r o n o u n c e d o n t e s t t h a n

o n c o n t r o l s i t e s. T h i s d i f f e r e n c e w a s t e s t ed b y S t u d e n t ' s

t t e st ( T a b l e V I ) : T h e d i f f e r e n c e w a s s i g n i f ic a n t i n t w o

b u c c a l s i t e s w h e r e t h e d i f f e r e n c e b e t w e e n b a s e l i n e a n d

f o l l o w - u p v a l u e s w a s n o t s i g n i f i c a n t o n t h e c o n t r o l s i te

( T a b l e V I ) . T h e r e d u c t i o n i n p o c k e t d e p t h w a s n o t a s -

s o c i a t e d w i t h r e c e s s i o n .

D I S C U S S I O N

T h e s e l e c t io n o f c a s e s f o r t hi s s t u d y w a s b a s e d o n

r a d i o g r a p h i c c r i t e r i a t o e s t a b l is h t h e p o s i t i o n o f t h e i m -

p a c t e d t e e t h . O n l y d e e p i n f r a o s s e o u s i m p a c t i o n s w e r e

c o n s i d e r e d : i n n o c a s e w a s t h e d i s ta n c e o f t h e c u s p o f

t h e i m p a c t e d t o o t h f r o m t h e o c c l u s a l p l a n e l e s s t h a n 1 7

m m o n t h e p a n o r a m i c r a d i o g r a p h . T h e p r o g n o s i s f o r

c o r r e c t i o n o f s u c h c a s e s m a y b e g u a r d e d 27 a n d t h e p e r i -

o d o n t a l o u t c o m e o f d e e p i n f r ao s s e o u s i m p a c t i o n s h a s

n o t y e t b e e n s t u d i e d .

S e v e r a l u n c o v e r i n g p r o c e d u r e s ( a p i c a l l y p o s i t i o n e d

f l a p a n d g i n g i v e c t o m y ) h a v e b e e n s u c c e s s f u l l y u s e d t o

t r e a t s u b m u c o s a l i m p a c t i o n s , j ' 9 ' a l t h o u g h t h e s e c a n n o t

b e s a f e l y a p p l i e d t o c a se s o f d e e p i n f r a o s s e o u s i m p a c t e d

m a x i l l a r y c a n i n e s , a s t h e y e n t a i l s e v e r e a l te r a t i o n s i n

p o s t o p e r a t i v e a n a t o m y . A s i g n i f i c a n t r e m o v a l o f b o n e

i s n e e d e d , w h i c h c a n r e s u l t i n t h e l o s s o f s u p p o r t i n g

t i s sues . 9 .1~ In ca ses o f bucc a l acces s , the m ucog ing iv a l

j u n c t i o n m a y b e a l t e r e d b y t h e a p i c a l p o s i t i o n i n g o f t h e

f l a p . P o s t o p e r a t i v e d i s c o m f o r t m a y b e s e v e r e . T h u s a

r e c o v e r i n g p r o c e d u r e ( r e p o s i t i o n e d f l a p ) w a s c o n s i d -

e r e d f o r d ee p i m p a c t i o n s . M a r k e d i m p r o v e m e n t s in

b o n d i n g m a t e r i a l s h a v e v i r t u a l l y e l i m i n a t e d t h e r i s k o f

a c c i d e n t a l l o s s o f th e a t t a c h i n g d e v i c e . M o r e o v e r , t h e

s t r e n g th o f b o n d i n g w a s t e s t e d b e f o r e r e p o s i t i o n i n g t h e

f l a p t o a v o i d t h e n e e d f o r r e e n t r i e s .

A p a r t i c u l a r r e c o v e r i n g p r o c e d u r e ( t u n n e l t r a c t i o n

a f t e r t h e r e f l e c ti o n o f a r e p o s i t i o n e d f l a p ) w a s u s e d

i n

th i s s tudy , where , in a l l the 15 cases , the p resence o f

t h e d e c i d u o u s c a n i n e w a s a s s o c i a t e d w i t h th e i m p a c t i o n

o f d e e p i n f r a o s s e o u s , f u l l y d e v e l o p e d a n d s e v e r e l y i n -

c l i n e d c a n i n e s ( T a b l e I ) , w h e r e a s t h e c o n t r a l a te r a l p e r -

m a n e n t c a n i n e h a d c o m p l e t e l y e r u p t e d . C o r t i c a l b o n e

r e s e c t i o n w a s r e d u c e d t o a sm a l l o p e r c u l u m , w h i c h w a s

n e e d e d t o a p p l y t h e a t t a c h i n g d e v i c e o n t h e c r o w n , a s

c l o s e l y a s p o s s i b l e t o t h e c u s p . T h e e x t r a c t i o n o f t h e

d e c i d u o u s t o o t h p r o v i d e d a n a t u r a l o s s e o u s t u n n e l ,

w h i c h w a s e a s i l y e x t e n d e d b y d r i ll i n g , t o r e a c h th e c u s p

o f t h e i m p a c t e d t o o t h . T r a c t i o n t h r o u g h t h e t u n n e l

e n

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T a b l e V . R e d u c t i o n o f p r o b i n g p o c k e t d e p t h a n d k e r a t i n i z e d t i s s u e w i d t h b e t w e e n b a s e l i n e a n d

f o l l o w - u p v i s i t s

Test

AVG SD

Control

AVG SD t

P D I 0 . 3 3 0 . 4 9 2 . 6 4 6 * 0 . 3 3 0 . 3 1 4 . 1 8 3 " *

P D 2 0 . 7 3 0 ,5 3 5 . 3 5 8 * * 0 . 1 7 0 . 3 1 2 . 0 9 2

P D 3 0 . 6 7 0 , 4 i 6 . 3 2 5 * * 0 . 1 7 0 . 3 1 2 . 0 9 2

P D 4 0 . 2 7 0 ,2 6 4 . 0 0 0 " ~ 0 . 2 7 0 . 2 6 4 . 0 0 0 * *

P D 5 0 . 4 0 0 , 2 8 5 . 5 2 7 * * 0 . 3 3 0 . 41 3 . 1 6 2 " *

P D 6 0 . 3 7 0 .3 0 4 . 7 8 4 * * 0 . 2 0 0 . 3 7 2 . 1 0 2

K T 1 . 23 0 . 6 2 7 . 6 6 8 * * 0 .5 3 0 . 5 2 4 . 0 0 0 * *

A bbr e v i a t i ons a s i n T a b l e I I I .

T a b l e V I . D i f f e r e n c e s b e t w e e n t e s t a n d c o n t r o l

s i d e s c o n c e r n i n g t h e r e d u c t i o n i n p r o b i n g

p o c k e t d e p t h a n d k e r a t i n i z e d t i s s u e w i d t h , f r o m

b a s e l i n e t o f o l l o w - u p ( T a b l e V )

Test control

T

A V G S D

t

P D I 0 0 . 5 0 0

P D 2 0 . 5 7 0 . 5 6 3 . 9 0 0 * *

P D 3 0 . 5 0 0 . 5 7 3 . 4 1 5 " *

P D 4 0 0 . 3 3 0

P D 5 0 . 0 7 0 .4 6 0 . 5 6 4

P D 6 0 . 1 7 0 . 4 1 . 5 8 I

K T 0 . 7 0 0 . 7 0 3 . 8 6 1 " *

A bbr e v i a t i ons a s i n T a b l e I I I .

N o t e : T h e l a s t d e c i m a l m a y d i f f e r f r o m t h e d i f f e r e n c e s c o m p u t e d o n

t h e a v e r a g e s b e c a u s e o f r o u n d i n g .

s u r e d a n e r u p t i o n p a t h t h a t c l o s e l y f o l l o w s t h e p h y s i -

o l o g i c p a t t e r n . T h e i m p a c t e d t o o t h w a s o r t h o d o n t i c a l l y

m o v e d b e t w e e n t w o n o r m a l l y s p a c e d c o r t i c a l p l a t e s

t o w a r d t h e c e n t e r o f t h e a l v e o l a r r i d g e , w h e r e s o m e

g i n g i v a w a s p r e s e n t e v e n o n t h e f a c i a l a s p e c t . 7 9 t~ N o

m u c o g i n g i v a l p r o c e d u r e w a s c a r r i e d o u t a t a n y t i m e t o

i n c r e a s e t h e k e r a t i n i z e d t i s s u e . T h e d e e p i n f r a o s s e o u s

c a n i n e s w e r e b r o u g h t i n t o t h e a r c h a n d p r o p e r l y a l ig n e d

w i t h o u t c o m p l a i n t s o f s i g n i f i c a n t d i s c o m f o r t , n e i t h e r

d u r i n g t h e p o s t o p e r a t i v e p e r i o d n o r d u r i n g t r a c ti o n . T h e

t i m e n e e d e d t o m o v e t h e i m p a c t e d t e e t h i n t o t h e a r c h

( p h a s e 2 ) , w a s n o t u n u s u a l l y l o n g ( T a b l e I I ) . T h e a g e

o f t r e a t m e n t w a s n o t c h o s e n b y t h e o r t h o d o n t i s t in m o s t

c a s e s : D e l a y s w e r e c a u s e d b y t h e r e f e r r i n g d e n t i s t o r

b y t h e p a t i e n t s . O n l y c a s e s w h e r e t h e a p e x h a d f u l l y

f o r m e d , w i t h r e d u c e d p o t e n t i a l f o r s p o n t a n e o u s e r u p -

t ion , were s e lec ted fo r th i s s tudy .

A t t a c h m e n t l o s s a n d r e c e s s i o n w e r e n e v e r o b s e r v e d

a t a n y s i t e e i t h e r a t t h e b a s e l i n e ( a f t e r t h e c o m p l e t i o n

o f t h e o r t h o d o n t i c a c t i v e t h e r a p y ) n o r a t t h e 3 - y e a r

f o l l o w - u p v is i t. T h e m a x i m u m p r o b i n g d e p t h w a s

3 m m . T h e s e o b s e r v a t i o n s , c o n s i d er e d t o g e t h er , i n d i-

c a t e a s a t i s f a c t o r y p e r i o d o n t a l s t a t u s b o t h o n t h e t e s t

a n d o n t h e c o n t r o l s i t e s . T h i s h e a l t h y s t a t u s w a s m a i n -

t a i n e d d u r i n g t h e 3 - y e a r f o l l o w - u p p e r i o d .

A t t h e b a s e l i n e , i n f l a m m a t i o n w a s o b s e r v e d ( b l e e d -

i n g i n d e x p o s i t i v e ) m o r e f r e q u e n t l y o n t h e t e s t s i d e ( 5

v e r s u s 2 p o s i t i v e s it e s ). A t t h e f o l l o w - u p v i s i t , n o d i f -

f e r e n c e i n i n f l a m m a t i o n w a s d e t e c t e d b e t w e e n t e s t a n d

cont ro l s ides (b leed ing a f t e r p rob ing in 3 o f the 15 s it e s

o n b o t h s i d e s ) .

S i n c e n o a t t a c h m e n t l o s s w a s o b s e r v e d , a l l o f t h e

p r o b i n g p o c k e t d e p t h s ( P D ) g r e a t e r t h a n 3 m m w e r e

m o s t l i k e l y p s e u d o p o c k e t s r a t h e r t h a n t r u e p a t h o l o g i c

p e r i o d o n t a l p o c k e t s . T h e a v e r a g e P D w a s s l i g h t l y , b u t

s ign i f i can t ly , g rea te r on the t e s t s ide in th ree s i t e s a t

the base l ine v i s i t (Tab le I I I ) , whereas i t was s ign i f i -

c a n t l y l e s s i n o n e s i te a t t h e f o l l o w - u p v i s i t ( T a b l e I V ) .

T h i s w a s d u e t o a c o m p a r a t i v e l y g r e a t e r d e c r e a s e i n t h e

p r o b i n g d e p t h o n t h e t e s t s i d e ( T a b l e V a n d V I ) . P s e u -

d o p o c k e t s a r e p h y s i o l o g i c o n f r e s h l y e r u p t e d t e e t h , b u t

t end to dec rease l a te r , un t i l the su lcus reaches a s t ab le

d e p t h ? 2 I n t h e s e c a s e s , t h e b a s e l i n e v i s i t w a s m a d e a t

t h e e n d o f t h e o r t h o d o n t i c t r e a t m e n t . A t t h i s t i m e , t h e

i m p a c t e d c a n i n e s h a d j u s t c o m e i n t o t h e i r f i n a l p o s i -

t i o n s , w h e r e a s t h e c o n t r o l t e e th h a d a l r e a d y b e e n i n t h e

a r c h f o r a t l e a st 2 y e a r s . I n o t h e r w o r d s , t h e r e d u c t i o n

o f p r o b i n g d e p t h w i t h o u t a t t a c h m e n t l o s s w a s d u e t o

a p i c a l m i g r a t i o n o f t h e g in g i v a l m a r g i n , w i t h r e d u c t i o n

in the f ree g ing iva .

T h e k e r a t i n i z e d t i ss u e w i d t h w a s n o t l e ss t h a n 2 m m

a t a n y s i t e ( t e st o r c o n t r o l ) ( T a b l e I I I a n d I V ) . T h e

d i f f e r e n c e b e t w e e n t h e t e s t a n d t h e c o n t r o l s i d e s w a s

s i g n i f i c a n t a t t h e b a s e l i n e , w i t h a h i g h e r b a n d o n t h e

e x p e r i m e n t a l ( i m p a c t e d ) t e e t h , i n b o t h b u c c a l a n d p a l -

a t a l c a s e s . T h i s r e s u l t w a s u n e x p e c t e d : T h e p r e s e n c e

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Volume

105

No l

o f a n e q u a l a m o u n t o f g i n g i v a w a s c o n s i d e r e d a n a m -

b i t io u s g o a l . T h i s d i f f e r e n c e w a s n o t o b s e r v e d 3 y e a r s

l at er . T h e w i d t h o f t h e a tt a c h e d g i n g i v a w a s c o m p u t e d

b y s u b t r a c t i n g t h e m i d b u c c a l p o c k e t d e p t h f r o m t h e

k e r a t in i z e d t i s su e w i d t h . T h e c o m p a r i s o n b e t w e e n t e st

a n d c o n t r o l s i d e s s h o w e d s t a t i s t i c a l l y i n s i g n i f i c a n t

( P > 0 . 1 ) a n d c l i n i c a l ly n e g l i g i b le m e a n d i f f e r e n c e s

b e t w e e n t e s t a n d c o n t r o l t e e t h a t b o t h b a s e l i n e ( 0 . 2 7

m m ) a n d f o l l o w - u p ( 0 . 1 3 m m ) v i s i ts . T h i s f a c t m u s t

b e a t t r i b u t e d t o t h e g r e a t e r d e c r e a s e i n t h e f r e e g i n g i v a

a n d a s s o c i a t e d p s e u d o p o c k e t d e p t h o n t h e t e s t s i d e s

( T a b l e V a n d V I ) .

I t s h o u l d b e e m p h a s i z e d t h a t n o d i f f e r e n c e w a s o b -

s e r v e d i n k e r a t i n i z e d t i s s u e w i d t h b e t w e e n t e e t h t r e a t e d

w i t h b u c c a l o r p a l a t a l f l a p s. T h i s r e s u l t w a s e x p e c t e d ,

s i n c e t h e f l ap w a s r e p p s i t i o n e d i n t o i ts o r i g i n a l p l a c e a t

t h e e n d o f s u r g e r y , w h i l e t h e e r u p t i o n o c c u r r e d a t t he

c e n t e r o f th e a l v e o l a r r i d g e , r e g a r d l e s s o f th e i n i ti a l

l o c a t io n o f t h e c u s p O f t h e i m p a c t e d t o o t h .

T h i s s t u d y w a s r e t r o s p e c t i v e , s i n c e i t i n c l u d e s o n l y

c a s e s o f u n il a te r a l d e e p i n f r a o s s e o u s i m p a c t i o n s , w h i c h

w e r e s e l e c t e d a f t e r t r e a t m e n t a c c o r d i n g t o t h e r e p o r t e d

e n t r y c r i te r i a . H o w e v e r , i t m u s t b e e m p h a s i z e d t h a t t h e

s t u d y i n c l u d e d a l l o f t h e p a ti e n t s w h i c h m e t t h e e n t r y

c r i t e r i a a n d w e r e t r e a t e d i n o u r p r a c t i c e i n t h e y e a r s

1 9 8 4 - 8 7 . D u r i n g t h i s t i m e , t h e tr e a t m e n t o f i m p a c t e d

c a n i n e s a n d t h e p e r i o d o n t a l c h a r t i n g h a d b e e n s t a n -

d a r d i z e d . G i v e n t h e r e l a t iv e r a r i t y o f t h e u n i la t e r a l i m -

p a c t i o n w i t h p e r s is t e n c e o f t h e d e c i d u o u s c a n i n e , a r e l-

a t i v e l y s m a l l s a m p l e c o u l d b e c o l l e c t e d . T h e r e f o r e a

p o w e r f u l t e s t (m u l t i p l e t ) w a s u s e d t o e n h a n c e t h e p o s -

s i b i l it y o f f i n d i n g d i f f e r e n c e s , i f a n y , i n p e r i o d o n t a l

p a r a m e t e r s , d e s p i t e t h e s a m p l e s i z e . I n f a c t , a b i a s w a s

i n t r o d u c e d , b e c a u s e o f m u l t ip l e c o m p a r i s o n s , w h i c h

i n c r e a s e s t h e s e n s i t i v i t y o f t h e t e s t. D e s p i t e t h e b i a s ,

n o c l i n i c a l l y r e l e v a n t d i f f e r e n c e w a s f o u n d . A m u l t i -

v a r i at e a p p r o a c h c o u l d b e u s e d t o t e s t d i f f e r e n c e s b e -

t w e e n m u l t ip l e r e s p o n s e v a r i a b l e s , b u t w o u l d n o t b e

a b l e t o d e t e c t e v e n l ~ g e d i f f e r e n c e s , g i v e n t h e s a m p l e

s i z e .

O N L U S I O N

D e e p i n f r a o s s e o u s c a n i n e s a s s o c i a t e d w i t h p e r s i s -

t e n t d e c i d u o u s t e e t h m a y b e s u c c e s s f u l l y a n d s af el 3r

t r e a t e d b y r e p o s i t i o n e d f l a p a n d t u n n e l t r a c t i o n t o w a r d

t h e c e n t e r o f t h e a l v e o l a r r i d g e .

P h y s i o l o g i c a t t a c h m e n t l e v e l s w i t h o u t g i n g i v a l

r e c e s s io n a n d a d e q u a t e a m o u n t s o f g i n g i v a m a y b e o b -

t a i n e d a n d m a i n t a i n e d o n t h e t r e a t e d t e e t h f o r a t le ~/ st

3 y e a r s a f t e r t r e a t m e n t . T h e s a m e r e s u l t s c a n b e e x -

p e c t e d f r o m t r e a tm e n t o f b u c c a l l y o r p a la t a ll y i m p a c t e d

t e e t h , p r o v i d e d t h a t t h e e r u p t i o n o c c u r s a t t h e c e n t e r o f

i h e a l v e o l a r p r o c e s s . N o g i n g i v a l a u g m e n t a t i o n p r o -

c e d u r e i s r e q u i r e d a n d t h e n a t u r a l a p p e a r a n c e o f t h e

t is s u e s m a y b e p r e s e r v e d .

T h e s e p o s i t i v e p e ri o d o n t a l o u t c o m e s w e r e o b s e r v e d

i n c a s e s o f d e e p i n f r a o s s e o u s i m p a c t i o n a f t e r t u n n e l

t r a c ti o n t o w a r d t h e c e n t e r o f t h e c re s t a n d m a y n o t b e

t r u e i f o t h e r p r o c e d u r e s i n v o l v i n g m o r e e x t e n s i v e r e -

m o v a l o f o v e r l y i n g b o n e a n d s o f t t is s u e a r e u s e d .

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