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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 1  |  Page : 35-39
A modified double pedicle graft technique and other mucogingival interceptive surgeries for the management of impacted teeth : A case series

1 Dept of Periodontics, KLE Dental College, Yeshwanthpur, Bangalore-22, India
2 Dept of Periodontics, JSS Dental College and Hospital, S.S.Nagar, Bannimantap, Mysore-570 015, Karnataka, India

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Maxillary canine is one of the most common teeth that are impacted. This accounts for 1-2% of all patients who attend orthodontic treatment. The key to achieve maximal eruption of these teeth is their surgical exposure and the role of periodontist in such situations is to provide a functional and satisfactory width of attached gingiva on the labial surface. There are different techniques to surgically expose the impacted teeth, namely--gingivectomy technique, apically positioned flap, closed eruption technique, modified apically positioned flap, double pedicle flap and free gingival graft. Selection of the procedure is dependent on the positioning of the tooth in relation to mucogingival junction and attached gingiva. In the present case series we describe three different techniques for uncovering of impacted teeth, which are apically positioned flap, closed eruption technique and a modified double pedicle graft specially planned for the situation. These procedures when selected diligently using sound selection criteria will create adequate width of attached gingiva which minimizes or eliminates the future mucogingival problems.

Keywords: Modified double pedicle graft, apically positioned flap, closed eruption, mucogingival interceptive surgery

How to cite this article:
Sunil S, Avinash B S, Prasad D, Jagadish L. A modified double pedicle graft technique and other mucogingival interceptive surgeries for the management of impacted teeth : A case series. Indian J Dent Res 2006;17:35-9

How to cite this URL:
Sunil S, Avinash B S, Prasad D, Jagadish L. A modified double pedicle graft technique and other mucogingival interceptive surgeries for the management of impacted teeth : A case series. Indian J Dent Res [serial online] 2006 [cited 2023 Jan 27];17:35-9. Available from:

   Introduction Top

In most individuals the permanent teeth erupt uneventfully and replace their primary precursors. However sometimes teeth fail to erupt. These unerupted teeth usually are diverted or aberrantly angulated and lose their potential to erupt [1]. These teeth are termed as impacted teeth. Depending on the positioning of the impacted teeth in relation to the adjacent erupted teeth, it can be termed as labially impacted, palatally impacted or impacted in middle of the alveolus. These impacted teeth can however be surgically uncovered using different surgical techniques.

The causes of impaction may be due to retained primary tooth, diversion of eruption of the tooth bud or idiopathic failure of eruption of unknown origin [1]. Other causes for impaction can be attributed to the presence of supernumerary teeth, soft or hard tissue obstruction [1]. In some cases the tooth may be impacted due to idiopathic rotation of the tooth during development. If the tooth bud does not upright itself as the root develops, it eventually would be impacted horizontally.

If the primary tooth is still present and the eruption of permanent tooth is delayed, the primary tooth should be extracted. If the root of the permanent tooth is still developing the tooth may erupt normally [2], but if the root apex of the impacted tooth has been formed completely, extraction of the primary tooth with surgical exposure and orthodontic extrusion of the impacted tooth becomes inevitable. During exposure of the permanent teeth care should be taken to preserve as much keratinized gingiva as possible and if no keratinized tissue is present on the labial side of the impacted tooth, procedures that create enough keratinized tissue should be used.

Adequate amount of keratinized gingival tissue under proper plaque control is a fundamental requirement for periodontal health [3]. When the teeth erupt uneventfully in the centre of alveolar ridge, an adequate amount of keratinized tissue will surround the erupted permanent tooth. Labially or buccally erupting teeth show reduced dimensions of gingiva since abnormal eruption of the permanent teeth restricts or eliminates the keratinized tissue between the erupting cusp and the deciduous tooth [4]. Lack of attached gingiva pose a potential risk for gingival recession in labially or buccally erupted teeth due to the possibility of accumulation of plaque and or traumatic tooth brushing during subsequent orthodontic treatment [5]. A good understanding between orthodontist and periodontist with a proper management of periodontal tissues can prevent these problems.

Localization and determination of tooth's exact position is the foremost step in surgical exposure of impacted tooth. In labial impactions, this often can be done by palpation, however in palatal and middle alveolus impactions, use of periapical radiographs and occlusal radiographs plays a major role. Use of buccal object rule is helpful in determining the location of impacted teeth [6].

Various surgical techniques can be employed to uncover the impacted teeth. The vertical location of the permanent tooth position to deciduous tooth and the amount of gingiva available will determine the selection of appropriate technique. The goal of these mucogingival interceptive surgeries is to prevent the ectopic permanent tooth from developing periodontal lesions in its most incipient stage [3].

Case 1

A 20 yr old female patient was referred from Department of Orthodontics to the Department of Periodontics, JSS Dental College and Hospital, Mysore for surgical exposure of impacted maxillary right canine [Figure 1, 2]. Clinical examination did not reveal anything significant about the position of impacted tooth. Radiographic procedures using an occlusal view and object localization technique using periapical radiographs revealed palatally impacted canine.

Obviously a closed eruption technique was chosen as no other technique was indicated and was performed under local anesthesia. A mucoperiosteal flap was reflected palatally extending from right second premolar to left canine for proper access and the prominence created by the tooth in the palatal bone was palpated. This was the guideline used for removal of bone over the tooth and to uncover the impacted tooth. The bone and the follicular connective tissue covering the tooth was removed and the area debrided well. Adequate amount of the crown was exposed for bonding the orthodontic button with the ligature wire tied to it [Figure - 3].

The flap was closed back after bonding the orthodontic button and the ligature was brought out of the mucosa, by piercing it, just above the impacted tooth. This ligature wire, which was projecting out of the palatal mucosa, was connected to the orthodontic arch wire using a Ballista spring 3 weeks later, force activation was started [Figure - 4]. The third week post-operative examination revealed adequate healing of the tissues [Figure - 4].

Case 2

A 22 yr old male patient was referred from Department of Orthodontics for surgical uncovering of multiple unerpted teeth [Figure 5, 6]. Crown of maxillary right canine was seen piercing through the labial gingiva located midway between the mucogingival junction and the alveolar ridge. Clinically the position and location of central and lateral incisors could not be appreciated. Object localization technique using radiographs showed labially placed central and palatally placed lateral incisors. The left first premolar was also impacted and the radiographs revealed abuccal impaction.

Surgical procedure of a modified technique

This case describes the incorporation of palatal mucosa and the adjacent mucosa of the edentulous ridge into a double pedicle graft described by Pini Prato, (2000) resulting in the successful establishment of an attached gingival margin. A routine gingivectomy procedure would have removed the entire attached gingiva leading to ensuing mucogingival problems. An intrasulcular incision was given around the right upper first premolar extending from the disto-buccal line angle to mesio­palatal line angle. Further a crestal incision was planned which would incorporate sufficient palatal mucosa to reconstruct the attached gingival margin on the labial aspect of canine. The incision was started from the premolar region and continued superiorly into the attached gingiva, in a curved fashion. This incision extended till the mucogingival junction area, approximately 4-5 mm mesial to the canine [Figure - 7]. The gingiva which was entrapped at the canine cusp was then released, elevated and was then moved to a position apical to the impacted tooth [Figure - 8]. Sutures were placed [Figure - 9] and the patient was recalled after 1 week for suture removal and orthodontic button placement. Six weeks post-op examination showed akeratinized tissue of about 4 mm labial to canine [Figure - 10]. This simple modification enabled us to incorporate the palatal mucosa and reconstruct the attached gingiva on the labial aspect of the canine, which compensated for the deficient labial mucosa on the canine. The modification was also necessary due to the presence of the adjacent edentulous area.

Surgical procedure for uncovering the impacted maxillary left first premolar

Clinically the position and location of first premolars could not be appreciated and the radiographs revealed buccally placed tooth. A closed eruption technique was planned and a crestal incision was given on the edentulous area extending from canine to second premolar. The crestal incision was continued as sulcular incision, one tooth mesial and one distal to the edentulous area on the labial side. The exploration through the incision revealed the crown of the first premolar. A minimal and thin bone was found covering the labial surface of the tooth. It was also seen that the tooth was placed too labially to attempt a closed eruption technique as the placement of orthodontic button would not allow primary flap closure. Thus, after thorough exploration using a periodontal probe and evaluating the labial tooth dimensions clinically, an apically positioned flap procedure was instantly planned and two vertical releasing incisions were given on either sides of the crestal incisions and a rectangular flap was elevated. After elevating the flap, half the crown portion on the buccal aspect of first premolar was visible; the remaining half was covered with follicular connective tissue and bone, which was removed to expose the crown portion of the tooth. The rectangular flap was then positioned apically and was sutured [Figure - 11]. The sutures were removed after one week and the healing was found to be satisfactory with adequate amount of keratinized tissue present on the buccal aspect of first premolar. At 6 weeks post-op akeratinized tissue of4 mm was seen labial to first premolar [Figure - 12]. Orthodontic activation of forces was started at 6 weeks.

   Discussion Top

The selection of the cases for this study was based on the clinical and radiographic criteria to establish the position of the impacted teeth. Several uncovering procedures like simple gingivectomy (window approach), [1] apically positioned flap (APF) [1],[3],[4], double pedicle graft [3],[4]and free gingival grafts [3],[4]have been successfully used to treat submucosal impactions. However, these techniques cannot be safely applied in cases like [1] -

  1. When APF is used for very high or laterally displaced impactions, accessory frena can be created in the vertical incision area and orthodontic relapse has been observed in some patients. Gingivectomy and double pedicle grafts can not be used in such situations.
  2. APT carries a greater risk of recession and uneven gingival margins as compared with the non impacted contralateral tooth. This can cause esthetic problems when the patient has high smile line.
  3. Mid-alveolar impactions are inaccessible without considerable labial bone removal.
  4. Impactions located near the nasal spine are impossible to leave uncovered.

Thus cases of midalveolar, palatal and deep intraosseous impactions need to be managed using closed eruption[1],[7] or tunnel traction techniques [8]. These procedures are very handy whenever indicated. However, closed eruption technique carries two potential problems. One is debonding of the bracket could occur and when this happens requires a second surgery to uncover and rebond the bracket to the impacted crown. Second, if improper orthodontic methods are used, a mucogingival problem can be created in the form of inadequate attached gingiva when the tooth erupts through the mucosa or close to the mucogingival junction. These two problems can be prevented if proper care is taken while planning the treatment and fixing the brackets.

The tunnel traction technique is used whenever the deciduous tooth is associated with the deep intraosseous impaction- Extraction of the deciduous tooth provides a natural osseous tunnel which can be easily extended by drilling, to reach the cusp of the impacted tooth. Enough tooth should be uncovered for the placement of orthodontic button/ bracket to aid in traction. The traction through the tunnel ensures an eruption path that closely follows the physiologic pattern, where the impacted tooth will be orthodontically moved between two normally spaced cortical plates towards the centre of the alveolar ridge [8].

This will ensure presence of adequate attached gingiva on the facial aspect.

Invariably all the procedures have some inherent drawbacks in them, which can be avoided by judicious selection of the procedure depending on the location of the impacted tooth in relation to the mucogingival junction and whether the tooth is placed labially, palatally or in midalveolarregions.

In the present case series a modified double pedicle graft, apically positioned flap and closed eruption techniques are used successfully to create adequate amount of attached gingiva.

In the first case where the patient presented with palatally impacted canine, closed eruption technique was the technique chosen for the treatment as all other procedures could not be performed. Adequate care was taken to overcome the problems of debonding and improper orthodontic mechanics associated with closed eruption techniques. During the surgical procedure, after bonding the orthodontic button, a hemostat was used to check the adequacy of bonding. A Ballista spring was then placed during orthodontic force application to create proper tooth eruption direction. Orthodontic force activation was started few weeks after the surgical procedure.

In the second case, multiple impacted teeth were present. Maxillary right central incisor, lateral incisor and canine were impacted and first premolar on the left side was also impacted. Object localization technique using radiographs showed labially placed central and palatally placed lateral incisors. All these teeth needed surgical exposure.

A gingivectomy procedure could lead to removal of all the attached gingiva for the canine and result in an alveolar mucosal attachment. An apically repositioned flap could not be used, as the gingival tissue was perforated in one area by the impacted canine and the keratinized mucosa available above the perforation would be inadequate. Hence a double pedicle graft specially modified for the present situation was planned and executed to success. This procedure was a modification of double pedicle graft given by Pini Prato. The presence of edentulous ridge, deficient labial keratinized mucosa on the canine and multiple impacted teeth necessitated the use of a different and unique technique to create sufficient keratinized labial gingiva. Thus the modified technique successfully created 4 nnn of keratinized tissue, labial to the impacted canine.

The surgical exposures of other impacted teeth were planned in the future appointments, but the incision, which was given for the double pedicle graft actually uncovered the crowns of lateral and central incisors also. Both the teeth did not have any bony covering, making the exposure easier. Orthodontic buttons were placed over all three teeth and activation of forces started at 6 weeks. The highly placed central incisor had no attached gingiva over the labial surface, butthe direction of eruption would be in such away that, it erupts through the crest of alveolar ridge (mimicking the eruption of natural teeth) and creating attached gingiva on its labial aspect. The impacted upper left first premolar was located on the labial side by radiographic procedures. A closed eruption technique was planned, but the exploration through the incision revealed the crown of the 1st premolar. A minimal and thin bone was covering the labial surface of it and the tooth was placed too labial to attempt a closed eruption technique as the placement of orthodontic button would not allow primary flap closure. Hence an APE procedure was instantly planned and this was done by giving 2 vertical incisions on mesial and distal side of the impacted tooth. The 6 fsub week post-op showed around 4 mm of keratinized gingiva buccal to 1st premolar and activation of orthodontic forces were started to get the tooth into occlusion.

This case series shows the use of 3 different surgical procedures for uncovering impacted teeth, which when used judiciously gives excellent results and helps in preventing future mucogingival problems. Future studies are required to evaluate the long term efficiency of such procedures.

   Conclusions Top

All surgical procedures used in this case series produced optimal keratinized tissue on the labial surface. This case series shows that the mucogingival interceptive surgeries, when used judiciously and at appropriate time can be helpful in preventing future mucogingival problems. This requires a coordinated approach on the part of both the periodontist and the orthodontist, which would ultimately benefit the patient in maintaining a trouble free periodontium.

   Acknowledgements Top

I would like to thank Dr. Harsha, my colleague for his valuable help in taking the photographs.

   References Top

1.Kokich VG, Mathews DP: Surgical and orthodontic management of impacted teeth, Dent Clin N Am, 37 [2]: 181-204, 1993.   Back to cited text no. 1    
2.Witsenberg B, Boering G: Eruption of impacted permanent upper incisors after removal of supernumerary teeth, hit J Oral Surg,10:423-431,1981.  Back to cited text no. 2    
3.Prato GP, Baccetti T, Magnani C,Agudio G Cortellini P: Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment. 1. A 7- year longitudinal study. J Periodontol, 71: 172-181, 2000.  Back to cited text no. 3    
4.Prato GP, Baccetti T, Giorgetti R, Agudio G, Cortellini P: Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment. H. surgically treated versus nonsurgically treated cases, J Periodontol, 71:182-187,2000.  Back to cited text no. 4    
5.Agudio G, Prato GP, De paoli S, Nevins M: Mucogingival interceptive surgery, Int. J Periodontics Restorative Dent, 5 [5], 49-9,1985.   Back to cited text no. 5    
6.Richards A. The buccal object rule. Dental Radiography and Photography, 3:53, 1980.  Back to cited text no. 6    
7.Vermette ME, Kokich VG, Kennedy DB: Uncovering labially impacted teeth: apically positioned flap and closed eruption techniques, Angle Orthod, 65 [1]: 23-34,1994.  Back to cited text no. 7    
8.Crescim A, Clauser C, Glorgetti R, Cortellini P, Prato GP: Tunnel traction of infraosseous impacted maxillary canines. A three-year periodontal follow up. Am J Ortho Dentofac Orthop,105:61-72,1994.  Back to cited text no. 8    

Correspondence Address:
S Sunil
Dept of Periodontics, KLE Dental College, Yeshwanthpur, Bangalore-22
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.29894

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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12]

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