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Clinical Cases Update: How would you design the surgical flap for this case? The ectopic canine

Ian Furst, Oral & Maxillofacial Surgeon, Coronation Dental Specialty Group

The solution we used;

The consensus from the comments is that most would have waited for the tooth to erupt.  In this case, the orthodontist had asked that tooth 1.4 be extracted and the 1.3 be further exposed and bonded.  Because we are a multi-disciplinary practice, I had the luxury of having the periodontist I work with take a look as well.  Both of us were concerned that tooth 1.3 would develop recession on traction.  Because there would be a good band of keratinized tissue between 1.3 and the extraction site of 1.4, I felt it would be relatively simple to rotate the flap above the tooth rather than risk recession.  Thanks to everyone for the great debate in the comments section.  See the video below for details on the flap design and outcome.  All the best.  Ian.

For all those with a surgical side.

A 16 year old boy with severe crowding has a buccally displaced tooth #1.3.  The plan is to extract teeth 1.4, 2.5, 3.5 and 4.5, further expose the crown of tooth #1.3 to place a bracket with chain and orthodontically erupt it into the plane of occlusion.

You notice that #1.3 has an insignificant band of heavily keratinized tissue to the buccal.

The decision is made to complete an apically repositioned flap and expose more of the clinical crown.  You’d like to reposition some of the more heavily keratinized tissue over the buccal CEJ .

Download the attached picture to draw, photoshop, paint-by-numbers or otherwise modify it to show your flap design for an apically repositioned flap. In the reply section upload your creation with a comment about why you’ve selected the flap design. Otherwise, send us your best team office picture and defend a choice to simply erupt the tooth.

My flap (with its problems, pitfalls and limitations) will get uploaded after the discussion.

Misplaced tooth #1.3

Tooth 1.4 will be extracted and 1.3 lacks attachement. How would you design the surgical flap for this case


  1. I agree that there is a lack of keratinized gingiva because of the eruption path above the mucogingival junction. However, since tooth 1.4 will be extracted, the canine will continue erupt. I would reassess the gingiva once the tooth has erupted.
    May be my opinion will cause some surprise, but that’s OK. Some patients has declined the gingival graft and it was not that bad after treatment. Many of them did not even need it after ortho treatment.

    • Ian Furst;
      Interesting call Sylvain; In this case the patient was going into ortho anyway for crowding throughout the arches. Not to spoil the ending, but the tooth was nearly in place after 3 months. How long would you wait for the tooth to erupt naturally?

  2. Once the tooth 1.4 will be removed, the 1.3 will emerge in its position and before making any flap or graft, we should wait and see after the complete repositionning of 1.3. I also think that since ortho and perio specialists do not agree to proceed to a gingival or keratizined tissue graft after or before the completion of the ortho treatment, in this case I think I would rather wait & see until the end of the ortho active treatment before reevaluating the need of any graft in this site (Buccal 1.3).
    This is my very humble opinion!

    • I completely agree with the wait and see approach with respect to the need for any gingival intervention. The 13 is lacking attached gingiva exclusively because it is very buccally (and apically) positioned in the arch _at the moment_. Once it fully erupts (or is helped to erupt fully) and is brought within the arch, the amount of attached gingiva around it will likely be similar to that which is already currently present on the buccal of adjacent teeth. Studies repeatedly show that the occasional lack of attached gingiva during the dental development in childhood and early teens often resolves on its own as the teeth complete their eruption (e.g., Andlin-Sobocki 1993, http://www.ncbi.nlm.nih.gov/pubmed/8450087 ). Furthermore, it has become appreciated in recent years that the absolute need for a “minimal zone of attached gingiva” is a myth (e.g., Mehta & Lim 2010, http://www.ncbi.nlm.nih.gov/pubmed/20403409). In the presence of good oral hygiene and in the absence of sulcular invasion by restorative materials, biologic health and stability can be maintained with a variety of widths of attached gingiva including its complete absence.

      • Ian Furst
        You’re leaving out some critical details David. In the first article they include the qualifier, “The results of this report, evaluating well-aligned teeth only….” on children 6-12 years old during normal eruption. In the second article, “The width of attached gingiva is not significant to maintain periodontal health in the presence of adequate oral hygiene. However, thin gingival tissues around teeth with restorations or undergoing labial orthodontic tooth movement may be more susceptible to recession”.

        My argument would be that the small amount of additional surgery at the time of the extraction might create a more predictable result in a shorter period of time. Also, if recession occurs after the tooth movement is complete (forced or otherwise) the options to repair would be more limited and, arguably, more involved. Thoughts?

        • Not sure how the quote you offer advances your argument. In this patient, oral hygiene is excellent, 13 is unrestored and will more palatally as part of treatment (or on its own) and not further buccally. Hence, the amount of attached gingiva will likely increase. Even if the amount of attached gingiva does not increase, studies have repeatedly shown that this situation is physiologic and stable in most patients and does not require routine intervention.
          Furthermore, I am not sure I can agree about the idea “that the small amount of additional surgery at the time of the extraction might create a more predictable result in a shorter period of time.” While I complement your desire to help the patient, you appear to be advocating a surgical intervention where one may not be needed based on the published literature.

          • First of all, thank you for participating in the online debate David. This is exactly what jcdablogs.ca is intended for; a detailed debate about a specific subject with someone that is well informed. I love this stuff.

            My understanding of your position is that the outcome of observation alone is a fait accompli (or very low risk of recession) and surgical intervention is not needed based on the published literature.

            I don’t think anyone will argue that the indications for the treatment of recession are changing. But labially displaced teeth and active ortho are a special situation. Section 5 of Mehta’s (2010) paper reviews this situation specifically and concludes that the risk of gingival recession during orthodontics is significant when teeth are labially displaced and/or have a thin biotype. Mehta concludes there are four indications for surgery to augment the gingival soft tissue. Number (ii) is “orthodontic movement outside alveolus in patient with thin tissue biotype. “ My assessment was that this case met this criteria.

            Trying to get a handle on the actual risk of recession in this tooth is less specific. Andlin -Sobocki (1993) recommended a conservative, observational approach for well-aligned teeth only. To apply that conclusion to this case is misleading. Yared (2006) found a rate of recession of 10% but was looking at mandibular incisors. I’ve found some other papers, but these seemed like the most pertinent.

            I agree the literature supports that extracting the 1.4 and leaving the tooth could have resulted in normal eruption and no recession. Also, that moving the tooth back into the alveolar housing could even restore the gingival height, if recession had occurred on movement.

            Regardless, I don’t agree that the risk of recession, especially with a plan to forcibly erupt the tooth from the orthodontist, was insignificant nor that the outcome of observation alone was without peril. That being said, you’ve definitely made me look at these cases with a more skeptical eye. Thank you.

  3. Dr. Elizabeth Vella Caruana

    Hello Dr. Furst, So happy to see your interesting cases here.
    I would not know how the apically reposition of keratinised tissue is done.
    I would ask if the surgery could include apical repositioning of the buccal frenum at the time of 14 extraction and then would think of monitoring growth.

  4. Apically repositioned flap is a good choice at time of extraction surgery. Alternatively, allowing eruption and then free Gingival graft can also be done.
    However, it might be possible to consider no extraction of bicuspids if there is not bimaxillary protrusion. If the issue is just crowding, lack of arch length can now be addressed in maxillary and mandibular arches by stable expansion through the use of modern passive self ligating brackets such as Damon. Expansion will result in a more esthetic profile, broader smile, and a more natural transition from cuspid to bicuspid.

  5. I would rate this patient’s hygiene as poor as evidenced by the abundant accumulation of plaque around all of the teeth with appliances, the gingivitis around 1.3, and the mildly hyperplastic tissue adjacent to the incisors. Whether or not this is a factor in the timing of surgery is a moot point but certainly the hygiene needs to be addressed ASAP for a number of reasons besides the perio. Regardless of that, I would suggest that the “wait and see” would be the better approach since some spontaneous improvement in the position of the canine should occur in response to the space made available by the extraction of the 1.4. By the way, it is not possible to accurately determine the inclination of the incisors but from the photo, it appears that the incisors are very upright. Was any consideration given to non-extraction treatment and opening space for the eruption of the 1.3? I agree with Lenny Jung in regard to the potential for an alternative approach, not just to the perio but even to the orthodontic management.

    • I have to be honest Paul, I was asked to extract 1.4 and expose and bone the 1.3. I’ve contacted the orthodontist for more details, but won’t have them until Monday. The short answer, is I’m not sure about consideration given to non-extraction treatment. Thank you for posting though.

  6. Ian: I look forward to the continuation of this discussion and the response from the orthodontist

  7. I cannot see the whole case. Chances are that I would not extract any bicuspids at all. Instead, I would possibly bracket the canine as well and proceed with a very light wire, such as a copper NiTi from Ormco. Possibly we might need an expander also. You can see case on my website http://www.PeterIsMyDentist.com that have fully blocked out canines and other teeth in teenagers and beyond that were successfully treated without extractions and surgery. Post treatment conebeams show good tooth and bone form. Thank you,

    Dr. Peter Olejarz

  8. Hi Ian,
    Hope you are well!
    If I were treating this patient, and have decided that it is an extraction case, (which it seems to be), this is the approach I would consider:
    Extract tooth 1.4. There is sufficient clinical crown present on tooth 1.3 to bond an eruption chain, or even a bracket. Orthodontically position tooth 1.3 into the arch. After the tooth has been “established” into its new position for a while, assess the periodontium. I would bet $$$ that no perio intervention would be required.
    Errol Nezon (your former paediatric dentist!)

    • Hey Errol – good to hear from you. 30 years later, too funny. The plan was to extract and expose, so I rotated a small flap over top of it after consult with perio. I’ll post the video of the outcome. Sorry for the delay in posting your comment; missed it on email. All the best. Ian.

  9. I’d carefully release the frenum when extracting the #1-4 then wait and see after the ortho Tx is complete. No rush to treatment here in my opinion.

  10. My comment would be that there are some more considerations than just the #13 attached gingiva . The total ortho treatment without more data can not be finalised in my mind whether extraction of 4 bicuspids are right way to go. However, if #14 is extracted then wait and see is a good approach to see if more surgery is need for #13 later on .

    • Thanks Susan. The case wasn’t really intended for an excercise in the whole ortho tx plan. The premise, is the decision to expose and bone it had been made – how would you rotate the tissue over top of it if you choose to. The concensus seems to be that most would risk the recession rather than do the rotation flap. I’ll post a video of the solution soon. Thanks. Ian.

  11. For all those on the non-extraction treatment side of the debate:
    I spoke with the orthodontist who tells me that the width of the maxillary and mandibular arches closely matched and didn’t feel he could reliably widen the maxillary arch (and hold it) without the same in the mandible. Regarding the decision to expose and actively erupt, the patient was 16 and the apex on the 1.3 was completely closed. He agrees that passive eruption would have been possible but the timing of it unpredictable at this age. He felt the active approach would likely shorten treatment time and be more predictable.

  12. Very nice video summary and discussion! Thank you for taking the time to share the case and moderate the debate.

  13. Thank you for a great presentation and explanation.

  14. Fantastic summary video and nice end result, Ian!

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