# Orthodontic Surgical Treatment of Impacted Mandibular Canines: Systematic Review and Case Report
## 5 Discussion  
The treatment of IMCs requires a multidisciplinary approach [27]. Just as spontaneous eruption occurs harmoniously and leads to tooth alignment in the presence of healthy periodontal tissues, the combined surgical-orthodontic treatment of an included element should simulate physiological eruption [28]. Therefore, the aim of orthodontic therapy is to guide the eruption of the tooth towards the center of the ridge, while surgical treatment should ensure that the dental and periodontal structures are respected to avoid damage at the end of therapy [19]. Regarding the treatment of IMCs and TMCs, several treatment options can be considered, including orthodontic traction, self-grafting, and surgical removal of the IMC. The strategy of surgically removing IMCs is the quickest and easiest. Although more difficult and complicated, orthodontic traction is the most effective strategy to restore ideal occlusion. Orthodontic mini-screws can be used as temporary anchorage devices to prevent the negative effects of anchorage loss [28]. From a therapeutic point of view, radiological diagnosis in late mixed dentition remains an important tool to detect incidents of mandibular canine inclusion. The clinical case presentation describes the surgical technique of IMC exposure and repositioning in the arch using a combined surgical-orthodontic treatment. Guided eruption techniques have several benefits in dentistry. They can be used for several  
Figure 10: Final intraoral photos of the patient: Element 4.3, recovered in the center of the dental arch, observed from the upper occlusal view (**a**), right lateral view (**b**), frontal view (**c**), left lateral view (**d**), and lower occlusal view (**e**). purposes, such as for tissue regeneration in either lingual [32] or conventional mechanics for impacted teeth [33]. There are two guided eruption techniques towards the center of the alveolar ridge: closed [34] and open [35; 36]. In the first technique, an orthodontic bracket is attached to the tooth surface after a full-thickness flap is lifted, and the tooth and bracket are then entirely covered with tissue; meanwhile, the latter (open) method consists of apical repositioning of the full-thickness flap, leaving the element open [36; 37; 38]. The closed guided eruption technique was adopted in the clinical case described [20]. In the open guided eruption technique, an operculum is made on the IMC and an orthodontic traction is placed on it [20]. In both techniques, the principles of conservative surgery, adhesive technique, and controlled orthodontic traction are applied. In the cases selected in this review, one case with gingival recession was found [28]. In all cases there was periodontal success of the treated IMCs [19; 20; 21; 22; 23; 24; 25; 26; 27; 39]. The reported clinical case was managed using the closed orthodontic eruption technique [15]. A mucoperiosteal flap was prepared with preservation of the interdental papillae, elevated to full thickness to allow minimal exposure of the included tooth for bracket adhesion. The minimal removal of cortical bone and pericoronal tissue, as well as the application of light forces during traction [40], also seems to explain the favorable periodontal outcome. Some authors state that surgical exposure of the enamel-cement line predisposes patients to a greater risk of gingival recession and bone loss [41]. Finally, repositioning the flap in its original position maintains the entire portion of keratinized tissue, and reduces discomfort during healing [42]. Since the element in the bone inclusion was associated with the presence of the corresponding deciduous element in the arch, the \"tunnel\" technique was applied, as originally described by [PERSON] et al. in 1994 [15]. The extraction of the deciduous element creates a natural bone tunnel, and traction through this tunnel simulates a physiological eruption. The tooth is orthodonically pulled towards the center of the ridge, allowing the preservation of keratinized gingival tissue and subsequent periodontal health [34].