PATIENTS’ PERCEPTION OF RECOVERY AFTER SURGICAL EXPOSURE OF IMPACTED MAXILLARY CANINES WITH OPEN AND CLOSED TECHNIQUE A PROSPECTIVE OBSERVATIONAL STUDY

Lynn Hauspy Student number: 00707305 Promotor: Prof. dr. Guy De Pauw Copromotor: dr. Liesbeth Temmerman A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree of Master after Master in Orthodontics Academic year: 2016 – 2017

PATIENTS’ PERCEPTION OF RECOVERY AFTER SURGICAL EXPOSURE OF IMPACTED MAXILLARY CANINES WITH OPEN AND CLOSED TECHNIQUE A PROSPECTIVE OBSERVATIONAL STUDY

Lynn Hauspy Student number: 00707305 Promotor: Prof. dr. Guy De Pauw Copromotor: dr. Liesbeth Temmerman A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree of Master after Master in Orthodontics Academic year: 2016 - 2017

De auteur(s) en de promotor geven de toelating deze Masterproef voor consultatie

beschikbaar te stellen en delen ervan te kopiëren voor persoonlijk gebruik. Elk ander

gebruik valt onder de beperkingen van het auteursrecht, in het bijzonder met

betrekking tot de verplichting uitdrukkelijk de bron te vermelden bij het aanhalen van

resultaten uit deze Masterproef.

Datum 2/05/2017

Lynn Hauspy Prof. Dr. G. De Pauw

Acknowledgements

Over the past four years I have put my theoretical knowledge into practice to conduct

research by myself for the first time.

Writing this thesis went with ups and downs, but today I look back with pride on its

successful completion.

I would like to use this opportunity to thank the people I could often turn to for

guidance.

I would first like to thank my promotor prof. dr. G. De Pauw and copromotor dr. L.

Temmerman for their professional help and support in this process. I am very grateful

for their time and effort to steer this thesis in the right direction during our monthly

contacts.

I would like to express a special thanks to prof. dr. G. De Pauw for having given me

the chance to start the postgraduate training in Orthodontics. It was a dream come

true and I can never thank him enough for the opportunity.

Secondly, I would like to thank all maxillofacial surgeons for their efforts in including

patients for this study. Without their participation this thesis would not have been

successful.

Also a big thanks goes out to the four lovely ladies who graduate with me for their

support in difficult times and especially for all the fun moments we had together!

Finally, I would like to express my very profound gratitude to my parents and my

boyfriend for providing me with support and encouragement throughout my four

years of study in orthodontics and throughout the process of researching and writing

this thesis.

This accomplishment would not have been possible without them.

Table of contents

Abstract (Eng) .............................................................................................................. 1

Abstract (Ned) .............................................................................................................. 2

1. Introduction ............................................................................................................ 3

1.1 Definition of impaction/displacement ............................................................... 3

1.2 Maxillary canine impaction ............................................................................... 3

1.2.1 Prevalence ................................................................................................. 3

1.2.2 Aetiology and complications ...................................................................... 4

1.2.3 Diagnosis ................................................................................................... 5

1.2.3.1 Clinical examination ............................................................................ 5

1.2.3.2 Radiographic examination ................................................................... 6

1.2.4 Treatment options .................................................................................... 10

1.2.4.1 Prevention ......................................................................................... 10

1.2.4.2 No treatment ...................................................................................... 11

1.2.4.3 Autotransplantation ........................................................................... 11

1.2.4.4 Prosthetic replacement ...................................................................... 12

1.2.4.5 Extraction .......................................................................................... 12

1.2.4.5.1 Canines ....................................................................................... 12

1.2.4.5.2 Lateral incisors (as a means of prevention) ................................ 13

1.2.4.5.3 First premolars (as a means of prevention) ................................ 13

1.2.4.6 Orthodontic space opening and rapid maxillary expansion ............... 13

1.2.4.7 Surgical exposure .............................................................................. 14

1.2.4.7.1 Open exposure technique ........................................................... 14

1.2.4.7.2 Closed exposure technique ......................................................... 15

1.3 Patients’ perceptions and duration of surgery ................................................ 16

1.4 Aim of the study ............................................................................................. 18

2. Materials & Methods ............................................................................................ 19

2.1 Research of literature ..................................................................................... 19

2.2 Study design and sample selection ............................................................... 21

2.3 Data collection ............................................................................................... 22

2.3.1 Patients’ perceptions ............................................................................... 22

2.3.2 Duration of treatment ............................................................................... 23

2.4 Statistical data analysis .................................................................................. 23

3. Results ................................................................................................................ 24

3.1 Pain intensity .................................................................................................. 25

3.2 Oral discomfort ............................................................................................... 30

3.3 Medication use ............................................................................................... 37

3.4 Impairment ..................................................................................................... 40

3.5 Six months post-operative ............................................................................. 47

4. Discussion ........................................................................................................... 49

5. Conclusion ........................................................................................................... 55

6. Reference list ...................................................................................................... 56

1

Abstract (Eng)

AIM: In this prospective observational study patients’ perception of recovery after

surgical exposure of palatally impacted canines treated with an open or closed

technique was evaluated.

MATERIAL AND METHODS: In 37 patients (22 female, 15 male; mean age 16 years

old) a palatally impacted canine was diagnosed. To expose the canine, the surgeon

could select a closed or open technique. All patients received a Health-Related

Quality of Life (HRQOL) questionnaire they filled in from the day of exposure until 6

days after surgery and again six months later.

In the questionnaire patients’ perception of recovery regarding pain, swallowing,

bleeding and comfort was assessed. Secondary, the impact of different parameters

such as gender, age and duration of surgical exposure was evaluated. Statistical

analysis was performed using the Mann-Whitney U-test and the Kruskal-Wallis test

within statistical software package ‘SPSS 24.0 for Windows’. Significance level was

set at p=0.05.

RESULTS: Overall recovery time, set as the day a patient scores 1 or 2 out of 5

regarding pain, was found in most patients after 3 days. Between the closed and the

open group no significant differences were found (p=0.479).

Oral discomfort such as bleeding after exposure was low in all patients from day 3

after surgical exposure, whereas for swallowing a score equal to or lower than 3 was

only achieved on day six. With the exception for bleeding on the day after exposure

(p=0.031), for both parameters (bleeding and swallowing) no significant differences

were found between the closed and the open group.

The median duration of surgical exposure was 19 minutes for the open group and 29

minutes for the closed group, a difference that was statistically significant (p=0.039).

CONCLUSIONS: According to the results of the questionnaires there was no significant

difference in the perception of patients treated with an open or closed technique. The

duration of surgical exposure was significantly shorter in the open technique.

It can be stated that six months after exposure all patients, regardless of their group,

were completely healed.

2

Abstract (Ned)

DOEL: In deze prospectieve observationele studie werd de patiëntenperceptie

omtrent herstel na chirurgisch vrijleggen van palataal ingesloten hoektanden, aan de

hand van een open of gesloten techniek, geëvalueerd.

MATERIAAL EN METHODEN: In deze studie werden 37 patiënten (22 vrouwen, 15

mannen; gemiddelde leeftijd 16 jaar) gediagnosticeerd met een palataal ingesloten

hoektand. Om de hoektand vrij te leggen, had de chirurg de keuze gebruik te maken

van de open of gesloten techniek. Aan alle patiënten werd gevraagd een Health-

Related Quality of Life (HRQOL) vragenlijst in te vullen op de dag van de ingreep tot

6 dagen erna en opnieuw 6 maanden na de ingreep.

In deze vragenlijst werd patiëntenperceptie omtrent pijn, slikken, bloeding en

ongemak beoordeeld. Eveneens werd de impact van verschillende parameters zoals

geslacht, leeftijd en duurtijd van de ingreep geëvalueerd. Statistische analyse werd

gedaan aan de hand van de Mann-Whitney U-test en de Kruskal-Wallis test in het

statistisch software programma ‘SPSS 24.0 voor Windows’. Het significantieniveau

werd vastgelegd op p=0.05.

RESULTATEN: Bij de meeste patiënten werd de algemene tijd nodig tot herstel

gedefinieerd als de dag waarop een patiënt 1 of 2 op 5 scoort omtrent pijn,

vastgesteld na 3 dagen. Tussen de open en gesloten groep werden hieromtrent geen

statistische verschillen gevonden (p=0.479). Oraal discomfort zoals bloeding was

laag in alle patiënten vanaf dag 3 na chirurgische vrijlegging, voor slikken duurde het

echter tot de 6de dag na vrijleggen om een score ≤ 3 te bekomen. Met de

uitzondering van bloeding de dag na vrijleggen (p=0.031), werden voor beide

parameters (bloeding en slikken) geen significante verschillen gevonden tussen de

open en gesloten groep. Voor de duurtijd van chirurgisch vrijleggen werd een

mediaanwaarde van 19 minuten voor de open groep en 29 minuten voor de gesloten

groep gevonden, een verschil dat statistisch significant bleek (p=0.039).

CONCLUSIES: Volgens de resultaten van de vragenlijsten was er geen significant

verschil in de perceptie van de patiënten behandeld met een open of gesloten techniek.

De duur van chirurgisch vrijleggen was significant korter in de open techniek.

Gesteld kan worden dat zes maanden na de ingreep alle patiënten volledig waren

genezen, ongeacht tot welke groep zij behoorden.

3

1. Introduction

1.1 Definition of impaction/displacement

Under normal circumstances teeth erupt when half to three quarters of their final root

length has developed (1).

When root development might have finished, but spontaneous eruption is not

expected it can be defined as ‘impaction’ (1).

The anomalous infraosseous position of teeth before the expected time of eruption

can be defined as ‘displacement’ (2).

1.2 Maxillary canine impaction

The canine is situated in a strategic position between the anterior and posterior

region of the dental arch and plays an important role in functional occlusion and

aesthetics of an attractive smile (3).

Maxillary canines have the longest period of development, as well as the longest and

most tortuous course to travel from their point of formation until they reach their final

destination in full occlusion (4).

Usually, maxillary canines erupt around a mean age of 11 years old in girls, whereas

in boys they erupt around a mean age of 11.7 years old (5).

1.2.1 Prevalence

After the third molar, the maxillary canine is the second most commonly impacted

tooth (2,6).

Concerning impaction there is a discrepancy between the maxilla and the mandible.

In the maxilla, canine impaction occurs 2 times more often than in the mandible (2,7).

According to several authors the incidence of impaction of a maxillary canine varies

between 1% and 3%, depending on the population studied (7,8).

Impaction can occur in two possible forms, namely buccal impaction or palatal

impaction. In Caucasians, the ratio of palatal to buccal impaction reaches 8 to 1,

meaning that palatal impaction occurs more frequently (2).

In girls canine impactions are twice as common than in boys (2,3).

4

1.2.2 Aetiology and complications

The exact aetiology of impacted canines is not yet known and many possible causes

have been cited. The causes of anomalous eruption of teeth can be generally divided

in two categories, namely either general or localized (9,10). Generalized causes

include endocrine deficiencies, febrile diseases and irradiation. The most common

causes for canine impactions are usually localized and are the result of one, or a

combination of the following factors (7):

• Tooth size-arch length discrepancies

• Prolonged retention or early loss of the deciduous canine

• Abnormal position of the tooth bud

• Presence of an alveolar cleft

• Ankylosis

• Cystic or neoplastic formation

• Dilacerations of the root

• Iatrogenic origin

The absence of the maxillary lateral incisor, its variation in root size as well as its

variation in the timing of root formation has also been implicated as an important

etiological factor associated with canine impaction (11-13). The prevalence of the

lateral incisor root with the right length, formed at the right time, is an important

variable needed to guide the mesially erupting canine in a more favourable distal and

incisal direction (7). This phenomenon is called “the guidance theory” by Miller (1963)

and Bass (1967) (12,14). They concluded that in the absence of the guiding influence

of the lateral incisor, the canine continues to erupt in its initial mesial and palatal

path. The canine then becomes impacted in the palatal area and fails to complete its

eruption.

This multifactorial aetiology may explain why canine impactions occur even when

other dental relationships are apparently normal, or in cases where lateral incisors

are missing when more than sufficient space is available (7).

Shafer et al. (15) described that the following complications (sequelae) can occur

with canine impaction:

• Labial or lingual malpositioning of the impacted tooth

• Migration of the neighbouring teeth, which results in loss of arch length

• Internal resorption

5

• Dentigerous cyst formation

• External root resorption

• Infections because of partial eruption

• Combinations of the complications above

These possible complications are showing the need for close observation of the

development and eruption of these teeth during the routine dental examinations of

the growing child (15).

1.2.3 Diagnosis

Patients are mostly unaware that they have an impacted tooth, since there is no pain,

discomfort or swelling. Also, it is not obvious to laypeople that there is a missing

tooth, since the deciduous tooth may not shed naturally in these circumstances. For

these reasons patients do not go to their dentist complaining of an impacted tooth. As

a general rule, it is the paedodontist or general dental practitioner who, during a

routine dental examination, discovers the existence of a retained deciduous tooth

(16).

Once canine impaction is suspected, it is important to identify the position of the

tooth.

The diagnosis of canine impaction is based on both clinical and radiographic

examination.

1.2.3.1 Clinical examination

The first step in diagnosing an impacted maxillary canine is visual inspection.

The following clinical signs might indicate a possible impaction (3,7):

• Differences in eruption sequence in comparison to the contralateral side

• Delayed eruption of the permanent canine or prolonged retention of the

deciduous canine beyond 14 to 15 years of age

• Absence of a normal labial canine bulge

• Presence of a palatal bulge

• Delayed eruption, distal tipping or migration of the lateral incisor Secondly a swelling labially or palatally of the alveolar process is searched by

manual palpation.

6

1.2.3.2 Radiographic examination

In addition to clinical examination, radiographic assessment is crucial to define the

exact position of the impacted canine.

Several different radiographic techniques for determining the position of unerupted

maxillary canines have been advocated.

Periapical radiographs

A periapical film offers a two-dimensional representation of the dentition, in which the

relation of the canine to the neighbouring teeth both mesiodistally and

superoinferiorly can be seen. However, to be able to evaluate precisely the location

of the canine buccolingually, a second periapical film should be taken (3) using the

“buccal object rule”, or the rule of “same lingual opposite buccal” introduced by Clark

in 1909 (17). This method involves 2 radiographs using the same vertical angulations

but taken at different horizontal angles. Because of parallax, the more distant object

will appear to travel in the same direction as the tube shift, and the object closer to

the tube will appear to move in the opposite direction (17).

Occlusal radiographs

In 1950 Hitchin (18) suggested the use of occlusal radiographs.

An occlusal radiograph can also help to determine the buccolingual position of the

impacted canine when used in conjunction with the periapical radiographs. However,

one condition when using occlusal radiographs is that the image of the impacted

canine is not superimposed on the other teeth (3).

Extraoral radiographs

Posteroanterior and lateral cephalograms can sometimes be of aid in determining the

position of the impacted canine, particularly its relationship to other facial structures,

such as the maxillary sinus and the floor of the nose (3).

Panoramic radiography (OPT) is the standard diagnostic method in orthodontics.

With relatively low radiation exposure, this provides an overview of the situation in

both jaws, the temporomandibular joints, and surrounding structures. Displaced

canines are often first found with this imaging procedure (19).

Based on the basic radiographic principle that an object placed closer to the film (and

thus further from the x-ray source) throws a smaller shadow than an object localized

7

at a greater distance from the film and closer to the x-ray source, it can be said that if

the unerupted tooth is closer to the x-ray tube on one side, it will appear larger on the

panoramic radiography. Unfortunately, the reliability of such a system has been

found very low (20,21).

The initial position of the impacted canine can be assessed on a panoramic

radiograph using the modified version of the criteria proposed by Ericson and Kurol

(22). The vertical and horizontal position of the impacted canine can be evaluated in

relation to the adjacent lateral incisor.

A horizontal line is drawn through the midpoint of the lateral incisor root to determine

the vertical position of the impacted canine. The impacted canine could have one of

two vertical positions:

• V1: the canine cusp is in the coronal half of the lateral incisor root

• V2: the canine cusp is in the apical half of the lateral incisor root

The horizontal position of the impacted canine was determined according to the long

axis of the adjacent lateral incisor. The impacted canine could have one of two

horizontal positions:

• H1: the canine cusp is distal to the vertical axis of the lateral incisor

• H2: the canine cusp is mesial to the vertical axis of the lateral incisor

(Figure 1) (23).

Pocket depth at the incisor distopalatal point was greater in the group of impacted

canines with initial vertical position V2 than in the group with initial vertical position

V1, while pocket depths in group H2 were greater at the incisor mesiolabial point and

premolar mesiolabial point, labial point and the distolabial point than in group H1.

This result suggests that the periodontal tissue of the adjacent teeth undergoes

increased stress during canine extrusion (23).

8

Figure 1: Schematic drawing illustrating the criteria used to define of the position of the impacted

canine. Horizontal: H1-the canine cusp is in the space between the premolar and the line drawn

through the long axis of the lateral incisor; H2-the canine cusp is in the space between the central

incisors. Vertical: V1-the canine cusp is in the coronal half of the lateral incisor root; V2-the canine

cusp is in the apical half of the lateral incisor root (23).

From the point of view of prognostic evaluation of canines with an anomalous

infraosseous position, radiographic variables visible on panoramic radiographs have

been used (22,24):

• The angulation and the position of the tooth

• The distance from the occlusal plane

• Possible superimposition on the roots of the adjacent teeth

The radiographic signs have also been correlated to the probability of spontaneous

eruption of displaced canines (22, 24).

The position of the impacted canine was evaluated on the panoramic radiograph by

using the 3 criteria proposed by Ericson and Kurol (22) (Figure 2):

• α-angle

the angle measured between the long axis of the impacted canine and the

midline

• d-distance

the distance between the canine cusp tip and the occlusal plane (from the first

molar to the incisal edge of the central incisor)

• s-sector

the sector where the cusp of the impacted canine is located:

o sector 1: between the midline and the axis of the central incisor

o sector 2: between the axis of the central incisor and the axis of the

lateral incisor

9

o sector 3: between the axis of the lateral incisor and the axis of the first

premolar

Figure 2: Panoramic radiographic features showing displacement of the upper left canine: α-angle, d-

distance, and s-sector (22).

CT scans, Cone Beam Computed Tomography (CBCT)

More recently, computed tomography (CT) has been proposed as an important

alternative for accurately defining the position of impacted canines. However, despite

the more detailed information yielded by this technique, the higher radiation dose and

cost outweigh its relative advantages (8,25).

A newly developed dental volumetric imaging device, CBCT, uses cone beam

radiation to gather similar information in the working range of dental radiography. The

effective absorbed radiation dose for a maxillomandibular imaging session is 50µSv

on average, depending on the settings and features of the CBCT. Traditional medical

CT results in an effective absorbed radiation dose from 124.9 to 528.4µSv for a

mandibular examination and 17.6 to 656.9µSv for a maxillary examination,

depending on the volume of the arch imaged and the operational settings of the CT

(26).

The proper localization of the impacted canine plays a very important role in

determining (3):

• The proper access for surgical approach

• The proper direction for the application of orthodontic forces

• The extent of the root resorption and damage to the adjacent teeth

10

1.2.4 Treatment options

Each patient with an impacted maxillary canine must undergo a comprehensive

evaluation of the malocclusion. The clinician should consider various treatment

options, which are listed below.

1.2.4.1 Prevention

The moment the practitioner detects early signs of ectopic eruption of the canines an

attempt should be made to prevent impaction and the occurrence of potential

complications (3).

Williams (27) suggested the extraction of the deciduous canine when the patient is 8

or 9 years of age as an interceptive approach in an attempt to avoid canine impaction

in Class I uncrowded cases.

Ericson and Kurol (22) suggested that the removal of the deciduous canine before 11

years of age would normalize the position of the ectopically erupting permanent

canines in 91% of the cases, if the canine crown is situated distal to the midline of the

lateral incisor. Conversely, the success rate is only 64% if the canine crown is

situated mesial to the midline of the lateral incisor.

In the mixed dentition period, the unerupted maxillary canine is often held too far

mesially by the mesiodistally wide crown of the unerupted first premolar immediately

distal to it. Together with the extraction of the deciduous canine, there is merit in the

simultaneous extraction of the adjacent first deciduous molar. The rationale for this is

that loss of the deciduous molar encourages a very rapid eruption of the first

premolar. With its eruption, the large crown of the tooth erupts and a much narrower

cervical root is substituted at the level of and distal to the unerupted canine. This

creates a potential void distal to the canine, which appears to encourage the latter to

drop back distally into the space that has relatively suddenly become available.

There is reason to believe that this may redirect a potentially wayward canine and

encourage its more normal eruption (16).

11

1.2.4.2 No treatment

When the patient does not desire treatment for the impacted tooth, it is important that

the clinician carries out periodical evaluations of the impacted tooth to look for any

pathological changes. The patient has to be informed that the long term prognosis for

retaining the deciduous canine is poor, regardless of its root length and how

aesthetically acceptable its crown is. In most cases the root will eventually resorb and

the deciduous canine will have to be extracted or spontaneously sheds (3).

1.2.4.3 Autotransplantation

Today transalveolar transplantation of impacted maxillary canines is considered to be

an alternative to orthodontic treatment or extraction, when the canine is in a

surgically complex position (28).

However, autogenous transplantation of canines can only be used in cases where

there is (29):

• Adequate space for the canine in the dental arch

• A canine of good morphology

• A possibility to remove the tooth without excessive damage to the root

Transalveolar transplantation offers the clinician greater flexibility in the treatment of

the impacted upper canine. Of special value is the short treatment time that comes

with this approach (28).

The procedure can be undertaken at any age but is more applicable to the older age

group where orthodontic treatment is unwanted because of aesthetic or social

reasons (29). In juvenile patients, conventional orthodontic treatment is preferred

(28).

If carried out successfully, autotransplantation of teeth ensures that the alveolar bone

volume is maintained due to physiological stimulation of the periodontal ligament

(30).

The prognosis of autogenous dental transplants clearly demonstrates that the rate of

success varies with the surgical technique, surgeon’s attention and skills, and

patient’s concern about the procedure (31).

The success rate of autotransplantation is influenced by a number of pre-operative

and post-operative factors like (32):

• Age of the patient

• Developmental stage of the graft

12

• Type of tooth transplanted

• Surgical trauma during graft removal

• Storage after removing the graft

• Recipient site

1.2.4.4 Prosthetic replacement

Another possible option in treatment of an impacted canine, though nearly never

used, is creating a prosthetic replacement. Here, orthodontic treatment is not

necessary and can be done immediately when there is enough space in the dental

arch.

The possible prosthetic solutions in replacing a canine are:

• A cantilever construction

• An implant

• Crown and brifge work

• Spoondenture

1.2.4.5 Extraction

1.2.4.5.1 Canines It should be emphasized that extraction of a canine is contraindicated. Such an

extraction might provide the most immediate solution, but restoration of functional

occlusion and aesthetics will be compromised (3). Extraction of the canine, although seldom considered, might be an option in the

following situations (3):

• If it is ankylosed and cannot be transplanted

• If it is experiencing external or internal root resorption

• If its root is severely dilacerated

• If the impaction is severe e.g., if the canine is lodged between the roots of the

central and lateral incisors, and orthodontic movement will jeopardize these

teeth

• If the occlusion is acceptable, with the first premolar in the position of the

canine and with an otherwise functional occlusion with well-aligned teeth

• If there are pathological changes, such as cystic formation or infection and the

patient does not desire orthodontic treatment

13

1.2.4.5.2 Lateral incisors (as a means of prevention) Impacted canines are sometimes associated with anomalous lateral incisors. At the

end of the treatment procedure, it is often necessary to alter the shape of these teeth

by prosthetic crowning, facings or composite build-ups, in order to make them

aesthetically acceptable, particularly those teeth that are peg-shaped. Palatal canine

cases generally have spaced dentitions, comprising small teeth, so that crowding and

the need for extractions in the overall treatment is unusual. Nevertheless, if extraction

has to be made to treat the overall malocclusion in these cases, consideration should

be given to the extraction of these malformed lateral incisors, as an alternative to the

conventional but healthy and anatomically perfect first premolars (16). Extraction of the lateral incisor is not a suitable procedure in most cases, but in those

patients where it is indicated, treatment time may often be very short. However, a

normally sized canine adjacent to a central incisor may create an unsatisfactory

appearance, particularly if the central incisor has a poor profile. Furthermore, by

lining up the canine and the first premolar in place of the lateral incisor and canine, a

discrepancy between upper and lower tooth sizes may compromise the occlusion

(16).

1.2.4.5.3 First premolars (as a means of prevention) Within the minority group of patients with impacted canines who are considered to be

extraction cases, a Class II relation or bimaxillary protrusion, the choice of teeth for

extraction usually devolves upon the first or second premolars. Extraction of the first

premolars offer much potential benefit to the displaced canine because the proximity

of these teeth facilitates the immediate provision of space close to the canine. It also

affords considerable opportunity for a spontaneous improvement in the canine

position, during the early leveling and aligning stages of mechanotherapy (16).

1.2.4.6 Orthodontic space opening and rapid maxillary expansion

An alternative and sometimes supplementary line of preventive treatment involves

the generous opening of space for the teeth, using orthodontic appliances. One of

the primary functions of orthodontic treatment preparatory to the treatment of

impacted teeth is the creation of space in the dental arches for the impacted teeth.

When this is done, unerupted teeth may often begin to improve their positions, as will

be seen on repeat radiographs, and may often erupt without surgical intervention

(16).

14

Over the past few years, there has been speculation regarding the efficacy of a rapid

maxillary expander as a means of prevention of canine impaction. There would not

seem to be any logical reason to suppose that skeletal midpalatal suture expansion

should provide the impetus for the spontaneous correction of an incipient canine

impaction - a laterolateral response to a sagittal problem. Nevertheless, Baccetti et

al. showed in their study that when using a rapid maxillary expander on 7.6 to 9.6

year olds the chances for eruption will increase from 13.6% for an untreated control

group to 65.7% for the group treated with rapid maxillary expansion (33,34). The

diagnostic parameter used by the authors for confirming impending impaction was a

reduction in the distance between the unerupted canine and the midline on a

posteroanterior cephalogram in these very young patients (16).

1.2.4.7 Surgical exposure

Nowadays surgical exposure of impacted canines is usually carried out whereas in

the past extraction of impacted canines was routinely performed.

The two most commonly used methods for exposing palatally impacted canines and

bringing them into the dental arch are the ‘open exposure technique’ and the ‘closed

exposure technique’.

1.2.4.7.1 Open exposure technique This technique is most useful when the canine has a correct axial inclination and

does not need uprighting during its eruption (3).

The progress of the canine eruption has to be monitored with radiographs (3).

When using the open exposure technique, a window of tissue is removed around the

tooth, and bone over the crown is removed, creating a window to expose the crown

of the canine. A periodontal pack is placed to prevent the window from closing. After

waiting for its spontaneous eruption, alignment with fixed appliances can start. Thus

in this method the canine moves into its correct position above the mucosa (35-37).

Several studies have described different advantages and disadvantages concerning

this topic.

It is described that the advantages of the open exposure technique include that the

tooth can be inspected at each visit (38-40), the operation time is shorter because

bonding is not attempted during the procedure (40) and according to the study of

Vanarsdall (39) there would be a faster eruption.

15

The main disadvantages of this technique described are:

• Spontaneous but slow eruption (3), which is contrary to the study of

Vanarsdall et al. (39)

• Delayed initiation of traction (41)

• Increased treatment time (3)

• Inability to influence the path of eruption of the impacted canine (3)

• Difficulty cleaning the area, greater risk of infection (38, 40, 41)

• Discomfort associated with the open wound (38,40,41)

• Wider bone exposure (41)

This method has also been associated with multiple periodontal concerns (37):

• Gingival recession (39-45)

• Bone loss (39)

• Decreased width of keratinized gingiva (43,46)

• Delayed periodontal healing (47)

• Gingival inflammation (43)

1.2.4.7.2 Closed exposure technique In the closed exposure technique the canine is exposed by an excision made of

covering mucoperiosteum and removal of bone. An attachment with a ligature

passing through the flap is placed on the exposed canine and the palatal flap is

repositioned. Soon after surgery the canine is gently brought into its correct position

using an orthodontic appliance. Thus, the canine moves into position beneath the

mucosa (3,35-37). Many advantages and disadvantages of the closed technique

have been reported in literature.

The closed exposure technique enables oral hygiene to be maintained more easily

and reduces post-operative discomfort (40). Other advantages might be rapid

healing, less discomfort, good post-operative hemostasis, conservative bone removal

and possibility of immediate traction (41).

On the contrary, direct inspection of the tooth is not possible post-operatively, re-

exposure is necessary in cases of bond failure and it may be difficult to keep the

tooth sufficiently dry during surgery to allow successful bonding (40,41).

16

1.3 Patients’ perceptions and duration of surgery

Nowadays, the level of a patient’s interest is high. The patient has the right to know

details regarding the surgical procedure and what can be expected during recovery

(41).

Questions about the duration of surgery and the extent of pain during and after

surgery are frequently raised by patients and their parents (48).

As a result the terms “quality of life” and “health related quality of life” have been

increasingly used in literature in the past decade, and at present it is impossible to

not take them into account (41).

Little research has been undertaken to explore patients’ perceptions of recovery after

surgical exposure of palatally impacted canines and to determine which of both

exposure techniques had the least impact on a patient’s daily life.

Over the years different statements are made in literature concerning the mean

duration of surgery.

In 1997 Pearson et al. (49) found an average operating time of 36 minutes in the

closed eruption group versus 12 minutes in the open eruption group.

Whereas in 2005 Chaushu et al. (41) reported the opposite. They found that the

exposure in the open eruption group was 44.6 minutes versus 36.4 minutes in the

closed eruption group, which makes the operation time in the open eruption group

longer compared to the closed eruption group.

About patients’ perceptions of recovery after surgical exposure different things have

been claimed.

Chaushu et al. (41) found that the post-operative recovery and the magnitude as well

as the duration of pain were longer when open exposure technique was used (41).

The median recovery time for palatally impacted teeth was significantly shorter in the

closed eruption group with regards to pain, analgesic consumption, ability to eat,

swallowing, everyday activity and food accumulation (41) (Figure 3).

17

Figure 3: Recovery time for pain, analgesic consumption, eating, swallowing, everyday activity and

food accumulation in closed versus open surgical exposures of palatally impacted teeth (41).

However, a remark concerning this study is that the participants had a range of

different ectopic teeth (including 14 impacted central incisors).

The clinical trial of Parkin et al. found no statistically significant differences in the

duration of surgery or in patient-reported outcomes after surgery between those who

were randomly allocated to receive an open or closed surgical exposure (48).

It appears that both techniques are acceptable to the patients and the operator. However, in 2008 Gharaibeh and Al-Nimri found in their study a mean surgical

duration time of 30.9 minutes for the open eruption technique compared to 37.7

minutes for the closed eruption technique, a difference that was statistically

significant (50).

In this study they also assessed the worst pain for 7 days after surgery. In the closed

eruption group 33% reported severe pain on the first day after surgery, while only

22% did in the open eruption group, a difference that was not statistically significant.

On the second day after surgery, only 2 patients reported severe pain in the open

eruption group versus zero in the closed eruption group (50).

In general no differences in perception of pain were found in this study between the

open and closed groups (50).

18

1.4 Aim of the study

Nowadays, the choice of technique for exposure of palatally impacted canines is

usually dictated by preference of orthodontist and/or surgeon.

To our knowledge, there is no evidence-based information that would suggest that

one technique is more preferable than the other concerning patients’ perception of

recovery.

Therefore, the aim of the present prospective observational study is to describe

patients’ perceptions of recovery after surgical exposure of palatally impacted

canines with open and closed technique.

19

2. Materials & Methods

2.1 Research of literature

A literature search was carried out in medical databases such as PubMed, Web of

Science and the Cochrane database.

A search strategy was set up to identify the articles concerning patients’ perception of

recovery after exposure of palatally impacted canines, using the open or closed

technique.

Following keywords were consistently used: “impacted”, “canine”, “periodontics”,

“orthodontics”, “surgical”, “exposure”, “palatal”, “radiography”, “patient perception”,

“recovery”

Inclusion of articles depended on following criteria:

• Restricted to English literature

• Exclusion of case reports

• The content of the abstract had to be related to impacted canines

The used methodology and results are listed in Table 1. The electronic search was

completed with manual research.

From PubMed 25 articles were retrieved, 2 from the Cochrane database, and no new

articles from Web of Science.

After reading the abstracts and discarding duplicates, only the relevant articles were

selected. Through checking the reference lists of these selected articles, new

relevant articles were found.

20

Database Key Words Results

PubMed Impacted AND canine 960

Impacted AND canine AND periodontics 37

Impacted AND canine AND orthodontics 441

Impacted AND canine AND surgical 398

Impacted AND canine and exposure 100

Impacted AND canine AND exposure AND periodontics 13

Impacted AND canine AND exposure AND orthodontics 71

Impacted AND canine AND exposure AND surgical 82

Impacted AND canine AND palatal 170

Impacted AND canine AND palatal AND periodontics 12

Impacted AND canine AND palatal AND orthodontics 108

Impacted AND canine AND palatal AND surgical 70

Impacted AND canine AND palatal AND exposure 30

Impacted AND canine AND palatal AND exposure AND periodontics

4

Impacted AND canine AND palatal AND exposure AND orthodontics

22

Impacted AND canine AND palatal AND exposure AND surgical

27

Impacted AND canine AND radiography 294

Impacted AND patient perception AND orthodontics 4

Impacted AND patient perception AND surgical 66

Impacted AND patient perception AND exposure 9

Impacted AND patient perception AND recovery 16

Web of Science Impacted AND canine AND periodontics 236

Impacted AND canine AND exposure AND periodontics 59

Impacted AND canine AND palatal AND exposure 29

Cochrane Impaction 8

Patient perception AND impacted canine 1

Table 1: Literature results

21

2.2 Study design and sample selection

The Ethics Committee of the Ghent University Hospital (ref. B670201628527)

approved this project (EC Project number 2016/0598) on the 30th of March 2016.

The study design will be a prospective observational study based on questionnaires.

Participants are healthy boys and girls who have unilateral or bilateral palatally

impacted maxillary canines seeking surgical exposure by a maxillofacial surgeon.

Selection was carried out based on the following inclusion and exclusion criteria.

Inclusion criteria:

• Palatally impacted maxillary canines (uni- or bilateral)

• Good general and oral hygiene

Exclusion criteria:

• Dental abnormalities like hyperdontia, hypodontia, congenital missing

teeth, etc.

• Compromising medical conditions

• Craniofacial syndromes

• Cleft lip or palate

• Periodontal disease

All study participants will have two types of intervention: 1. exposure of the palatally

impacted canine(s) and 2. orthodontic treatment with fixed appliances.

To expose the canine, the surgeon could select a closed or open exposure

technique.

Patients from different hospitals in Flanders (Belgium), meeting the inclusion criteria,

were asked to fill in a Health-Related Quality of Life (HRQOL) questionnaire from the

day of exposure until 6 days after surgery (Appendix 1). After receiving oral

information about the study, all patients and their parents signed an informed consent

form (Appendix 2,3,4).

All maxillofacial surgeons filled in a technical file with data (age, gender,

orthodontist’s name, surgeon’s name, tooth number(s), technique, duration of

treatment) concerning the patient and the surgery (Appendix 5).

22

The participants were asked to fill in the same questionnaire 6 months after exposure

of their canine(s), regarding their well-being at that moment (Appendix 6).

The main outcome measure will be the patients’ perception of recovery after surgery.

The setting of the study will take place at different hospitals where the maxillofacial

surgeons work.

• Ghent University Hospital, Ghent, Belgium

• AZ Saint Luke’s Hospital, Ghent, Belgium

• AZ Jan Palfijn, Ghent, Belgium

• AZ Saint-John’s Hospital, Bruges, Belgium

• Hospital East-Limburg, Genk, Belgium

• Antwerp University Hospital, Antwerp, Belgium

• AZ Alma, Eeklo, Belgium

• AZ Nikolaas, Sint-Niklaas, Belgium

• AZ Zeno, Knokke-Heist, Belgium

2.3 Data collection

2.3.1 Patients’ perceptions

To evaluate patients’ perceptions the subjects received, on the day of surgery, a

Health-Related Quality of Life questionnaire that consisted of fifteen questions they

had to fill in everyday, from the day of exposure until 6 days after surgery (Appendix

1).

In the questionnaire, patients’ perceptions of recovery regarding pain, swallowing,

bleeding, analgesic consumption and comfort was assessed. Secondary, the impact

of different parameters such as gender, age and duration of surgical exposure were

evaluated.

In the questionnaire patients were asked to mark, for each question, the number best

describing how they felt at that moment. A 5-point Likert scale was used for which the

key was as follows: 1, not at all; 2, very little; 3, some; 4, quite a lot; 5, very much.

The participants were also asked to fill in the same questionnaire 6 months after the

exposure of their canine(s) (Appendix 6).

23

2.3.2 Duration of treatment

Surgeons were asked to time the exposure of the palatally impacted canines from

their first incision until their last suture.

2.4 Statistical data analysis

Statistical analysis was performed using the statistical software package ‘SPSS 24.0

for Windows’.

Median value and interquartile range were calculated for each variable.

Differences between groups were tested using the nonparametric Mann-Whitney U-

test and the Kruskal-Wallis test for pain, swallowing and bleeding.

Significance level was set at p=0.05.

24

3. Results

Patient recruitment commenced at the beginning of April 2016 and finished at the

end of March 2017.

Forty-two patients underwent surgical exposure of palatally impacted canines using

an open or closed exposure technique.

Thirty-seven of the 42 patients completed the questionnaire. Three patients did not

submit their questionnaires despite several reminders. Two patients were excluded,

based on the exclusion criteria.

Consequently, of the 37 patients enrolled in this study, the open exposure technique

group comprised of 25 patients (9 boys, 16 girls) with a mean age of 16 years old

(SD 4 years), and the closed exposure technique group comprised of 12 patients (6

boys, 6 girls) with a mean age of 17 years old (SD 6 years). There were no significant

differences in age and gender between the two groups.

In total 15 maxillofacial surgeons participated in the study, working at different

hospitals in Flanders, Belgium.

The mean duration of surgical exposure was 19 minutes (SD 10 minutes) in the open

group and 29 minutes (SD 14 minutes) in the closed group.

These results showed that a statistically significant longer duration of surgical

exposure was recorded in the closed technique when compared to the open

technique (p=0.039).

25

3.1 Pain intensity

A trend was found where pain through six days after exposure rapidly decreased. On

the day of surgery (D0), 5.4% of patients experienced no pain, whereas 48.6% noted

a moderate pain and 45.9% even reported severe pain. During the following days

after surgical exposure, the pain score decreased. Where on the day of exposure

45.9% of patients gave pain a score of 4-5 of 5, this percentage dropped to 27% on

the first post-operative day (D1). On the sixth day after surgery (D6) 48.6% of

patients reported to be free of pain and only 14.3% described severe pain. (Figure 4)

Figure 4: Proportion of patients reporting no pain (score 1 of 5), less to moderate pain (score 2-3 of 5)

and severe pain (score 4-5 of 5) during six days after surgical exposure.

0

10

20

30

40

50

60

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

nopain

lesstomoderatepain

severepain

26

Patient assessments of pain during six days after surgical exposure did not differ

significantly between men and women.

When evaluating general pain over six days, 64.3% of men reported moderate pain

and 35.7% reported severe pain. With the women, an equal distribution was found

between moderate and severe pain, both being 50%.

On the day of exposure (D0) 54.5% of women reported having severe pain (score 4-

5 of 5), whereas only 33.3% of men did. During the following post-operative days a

more rapid decrease in pain was found in women compared to men. (Figure 5)

Figure 5: Proportion of patients reporting general pain as severe (score 4-5 of 5) in men and women.

There was a difference in reporting pain according to age. When participants were

divided into two groups, namely patients younger than 16 years old and patients 16

or older, it were the older patients that reported less severe pain when compared to

the younger ones, 37.5% and 50% respectively.

0

10

20

30

40

50

60

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

men

women

27

The overall amount of pain was described as low to moderate (score 1-3 of 5) in

45.8% of patients in the open group and 80% in the closed group.

When explicitly looking for severe pain (score 4-5 of 5), 54.2% of patients in the open

and 20% of patients in the closed group reported it.

On the day of surgery (D0) 45.9% of patients reported severe pain, namely 52% in

the open and 33.3% in the closed group. The first post-operative day (D1) severe

pain was reported in 28% of the open and in 25% of the closed group.

On the second post-operative day (D2) the percentage of patients reporting severe

pain had decreased to only 12% in the open group, but was still 33,3% in the closed

group. On day 3 after surgery (D3) an increase in patients reporting severe pain was

found in the open exposure group, where in the closed exposure group a further

decrease was found, to 24% and 16.7% respectively.

On the fourth post-operative day (D4) the percentages for severe pain became 12%

in the open group and 8.3% in the closed group.

It was on day 5 and 6 after surgery (D5 and D6) that no patients in the closed group

complained about severe pain, where it was about 20% in the open group. (Figure 6)

Figure 6: Proportion of patients reporting pain as severe (score 4-5 of 5) in open and closed exposure

group.

0

10

20

30

40

50

60

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

28

When pain assessment was evaluated between groups on the day of exposure (D0)

and on the sixth day after exposure (D6), no significant differences were found

between the open and closed exposure group (p=0.486 and p=0.371). At the day of

exposure the mean value for pain was 4 in the open group versus 3 in the closed

group, whereas on the sixth day after exposure the mean value decreased to 2 for

the open group versus 1 for the closed. (Figure 7)

Figure 7: Boxplots reporting pain assessment on the day of surgery (Pain at D0) and on the sixth day

after surgery (Pain at D6) according to technique, namely open and closed exposure technique, the

differences not being statistically significant (p=0.486 and p=0.371).

On the fifth post-operative day (D5), a significant difference in pain level was found

between the open and closed technique (p=0.020). (Figure 8) Patients in the open

exposure group gave a median score 2 “very little” on the Likert scale 1 to 5, where

the patients in the closed exposure group gave a median score of 1 “not at all”, the

difference being statistically significant (p=0.020)

Figure 8: Boxplot reporting pain assessment the fifth post-operative day (Pain at D5), the difference

between open and closed technique being statistically significant (p=0.020).

29

Overall recovery time, set as the day a patient scores 1 or 2 out of 5 regarding pain,

was found in most patients after 3 days. Regarding recovery time, no significant

differences were found between the open and closed group (p=0.479).

Normally, patients should expect a recovery within 3 days after exposure of palatally

impacted canines, whether the open or the closed technique was used.

When comparing unilateral exposure versus bilateral exposure, there was a

significant longer duration time needed for bilateral exposure (p=0.021). Also, when

comparing unilateral exposure versus bilateral exposure significant differences

regarding pain were found for day 4 (p=0.037), 5 (p=0.006) and 6 (p=0.006) after

exposure. (Figure 9)

Figure 9: Boxplot reporting pain assessment on the 4th, 5th and 6th post-operative day, the difference between unilateral and bilateral exposure being statistically significant (p=0.037, p=0.006, p=0.006).

As seen in the boxplots above, the mean value for pain the fourth post-operative day

(Pain at D4) was 3 in the bilateral exposure group, versus 2 in the unilateral exposure

group. At days 5 and 6 (Pain at D5 and Pain at D6), the mean value for pain was 3 in

the bilateral exposure group, versus 1 in the unilateral exposure group, indicating that

unilateral exposure was less painful than bilateral exposure was.

30

3.2 Oral discomfort

Concerning oral discomfort such as bleeding after surgical exposure most patients

reported a generally low discomfort. On the day of exposure (D0) 24.3% reported to

have severe bleeding, 45.9% reported moderate bleeding and 29.7% had no

bleeding. From the third post-operative day (D3) none of the patients reported severe

bleeding. (Figure 10)

Figure 10: Proportion of patients reporting no bleeding (score 1 of 5), less to moderate bleeding (score

2-3 of 5) and severe bleeding (score 4-5 of 5) during six days after surgical exposure.

For bleeding no significant differences were found between men and women.

Only the day after surgery (D1) a significant difference in bleeding was found

between the open and closed group (p=0.031). The median scores for the open and

the closed group were 1 and 2 respectively. (Figure 11) Thus the closed group

scored significantly higher with regard to bleeding on day 1 after surgery. The other

days no significant differences could be found between both techniques.

0

10

20

30

40

50

60

70

80

90

100

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

nobleeding

lesstomoderatebleeding

severebleeding

31

Figure 11: Boxplot reporting bleeding the first post-operative day (Bleeding at D1). The difference

between open and closed group being statistically significant (p=0.031).

Overall, the amount of bleeding was described as very low to non-existent in the

majority of patients. (Figure 12)

When explicitly looking for severe bleeding (score 4-5 of 5) during the six days after

exposure, it was found that on the day of surgery (D0) 20% of patients in the open

group and 33.3% of patients in the closed group reported severe bleeding. An

enormous decrease in percentages is seen one day after exposure (D1) with the

percentage dropping to 4% in the open and 8.3% in the closed group. The second

post-operative day (D2) severe bleeding is only reported in the open group, only 4%.

From day 3 after surgery none of the patients regardless of their group, reported

severe bleeding. (Figure 13)

When bleeding was described, most patients experienced a rather moderate amount

of bleeding. (Figure 14)

32

Figure 12: Proportions of patients reporting no bleeding (score 1 of 5) in open and closed exposure

group.

Figure 13: Proportion of patients reporting bleeding as severe (score 4-5 of 5) in open and closed

exposure group.

0

20

40

60

80

100

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

0

5

10

15

20

25

30

35

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

33

Figure 14: Proportion of patients reporting bleeding as less to moderate (score 2-3 of 5) in open and

closed exposure group.

When unilateral exposure was compared to bilateral exposure a statistically

significant difference in bleeding was found on the day of surgery (D0) (p=0.010). A

median value of 2 was seen in the unilateral exposure and 2.5 in the bilateral

exposure, indicating a statistically significant higher bleeding when bilateral exposure

is performed in comparison to unilateral exposure. (Figure 15)

Figure 15: Boxplot reporting bleeding on the day of exposure. The difference between unilateral and

bilateral exposure being statistically significant (p=0.010).

0

10

20

30

40

50

60

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

34

The ability to swallow after surgical exposure was quite high in most patients. A

minority of patients reported severe difficulties to swallow. On the day of exposure

(D0) 21.6% reported to have severe swallowing difficulties, but this percentage

decreased rapidly to none of the patients describing severe difficulties to swallow six

days after surgical exposure (D6). (Figure 16)

Figure 16: Proportion of patients reporting no difficulties to swallow (score 1 of 5), moderate difficulties

to swallow (score 2-3 of 5) and severe difficulties to swallow (score 4-5 of 5) during six days after

surgical exposure.

For swallowing, no significant differences were found in gender, technique or when

unilateral versus bilateral exposure comparison was made.

General swallowing, evaluated over the six days after surgical exposure, showed

little difficulties to swallow in 78.6% of the men and 85% of the women and more

difficulties to swallow in 21.4% and 15% respectively.

0

10

20

30

40

50

60

70

80

90

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

nodif?icultiesswallowing

moderatedif?icultiesswallowing

severedif?icultiesswallowing

35

On the day of exposure (D0) 26.7% of men reported severe difficulties to swallow

(score 4-5 of 5), whereas only 18.2% of women did. During the following post-

operative days a rapid decrease was found in both women and men, with on the sixth

post-operative day (D6) no severe difficulties to swallow nor in men nor in women.

(Figure 17)

Figure 17: Proportion of patients reporting general difficulties to swallow as severe (score 4-5 of 5) in

men and women.

When comparing patients younger than 16 years old and patients 16 or older, the

younger patients reported less severe difficulties in swallowing than did the older

ones, 5.6% and 31.3% respectively, the difference being not statistically significant

(p=0.078).

Almost all patients reported to have nearly no problems concerning swallowing

independent of whether they belonged to the open or the closed group. Only 16.7%

in the open group and 20% in the closed group reported great difficulties in

swallowing.

When explicitly looking for severe difficulties in swallowing (score 4-5 of 5), 24% of

patients in the open group and 16.7% of patients in the closed group complained

about severe swallowing problems on the day of surgery (D0). Already the first post-

operative day (D1) severe difficulties in swallowing were reported in only 8% of the

0

5

10

15

20

25

30

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

men

women

36

open and 8.3% of the closed group, demonstrating a huge improvement.

On the second post-operative day (D2), no patients in the open group complained

about difficulties in swallowing where they again do on the third, fourth and fifth day

after surgery (D3,D4 and D5), however in small numbers. For the closed group 8.3%

of patients reported difficulties in swallowing on the second and third post-operative

day (D2 and D3), where in later days no patients complained at all. (Figure 18)

Figure 18: Proportion of patients reporting difficulties in swallowing as severe (score 4-5 of 5) in open

and closed exposure group.

Also, when comparing unilateral and bilateral exposure, patients with bilateral

exposure had more difficulties to swallow than patients with unilateral exposure, the

difference not being significant (p=0.062).

In short, with the exception of bleeding the day after surgical exposure (p=0.031), no

significant differences were found in oral discomfort between the open and the closed

group.

0

5

10

15

20

25

30

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

37

3.3 Medication use

Overall drug use was low in patients participating in this study. On the day of surgery

(D0), 47.2% of patients were given ibuprofen. A decrease in use of analgesics was

found starting at the first day after surgery (D1), with 41.7% of patients already being

analgesic free. That percentage increased during the following days, with 71.4% of

patients being free of pain medication on the sixth day after surgery (D6).

Fortunately, only 2.8% of patients received antibiotics after exposure of palatally

impacted canines, sometimes in combination with ibuprofen. (Figure 19)

Figure 19: Medication use in patients after surgical exposure, during six days post-operative.

On the day of exposure (D0) no statistically significant differences in medication use

were found between the open and closed group (p=0.475). (Table 1)

As reported in Table 1, ibuprofen was prescribed in 41.7% of patients in the open

group and 58.3% of patients in the closed group followed by 20.8% in the open group

and 16.7% in the closed group taking paracetamol or a combination of paracetamol

and ibuprofen, 20.8% and 8.3% respectively.

Only 4 patients (16.7%) in the open group and 1 patient (8.3%) in the closed group

had no need for medication on the day of surgery (D0). (Table 1 and 2)

0

10

20

30

40

50

60

70

80

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

none

paracetamol

ibuprofen

paracetamol+ibuprofen

antibiotics

mouthrinses

antibiotics+ibuprofen

38

Also, when comparing medication use between the open and closed group, no

statistically significant differences were found at the sixth post-operative day (D6)

(p=0.428). (Table 3)

On the sixth day after surgical exposure (D6) 65.2% of patients in the open group

and 83.3% of patients in the closed group had no need to use any type of

medication. (Table 3)

opengroup closedgroup totalNone 4(16.7%) 1(8.3%) 5(13.9%)Paracetamol 5(20.8%) 2(16.7%) 7(19.4%)Ibuprofen 10(41.7%) 7(58.3%) 17(47.2%)Paracetamol+ibuprofen 5(20.8%) 1(8.3%) 6(16.7%)Antibiotics 0 1(8.3%) 1(2.8%)Mouth rinses 0 0 0Antibiotics +ibuprofen 0 0 0 Table 1: Medication consumption in terms of number of patients and percentages the day of surgical

exposure.

opengroup closedgroup totalMedication the first day 20 11 31 No medication the first day 4 1 5 Medication the sixth day 7 2 9 No medication the sixth day 16 10 26 Table 2: Medication consumption in terms of number of patients the day of surgical exposure and the

sixth day after.

opengroup closedgroup totalNone 15(65.2%) 10(83.3%) 25(71.4%)Paracetamol 3(13.0%) 1(8.3%) 4(11.4%)Ibuprofen 2(8.7%) 0 2(5.7%)Paracetamol+ibuprofen 2(8.7%) 0 2(5.7%)Antibiotics 0 1(8.3%) 1(2.9%)Mouth rinses 1(4.3%) 0 1(2.9%)Antibiotics +ibuprofen 0 0 0 Table 3: Medication consumption in terms of number of patients and percentages the sixth day after

surgical exposure.

39

Medication use in this study can be divided into analgesics and antibiotics. As

mentioned earlier, prescribing antibiotics is not very common. Ibuprofen and

paracetamol were the most commonly used analgesics prescribed when patients had

surgical exposure of palatally impacted canines.

On the day of surgical exposure (D0) an equal distribution of 83.3% in prescriptions

of analgesics was found for both groups. The day after surgery (D1) a decrease in

analgesic use was found in the open and closed group already. In the closed group

58.3% of patients were analgesic free, as were 45.8% in the open group on the first

post-operative day. (Figure 20)

Figure 20: Percentages of analgesic use in open and closed exposure group during six days post-

operative.

0

10

20

30

40

50

60

70

80

90

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

40

3.4 Impairment

Functional burdens such as absence from school or work and difficulties to perform

daily activities were generally low when patients had undergone surgical exposure of

palatally impacted canines. On the day of exposure (D0) 37.8% of patients reported

not being absent from school. This percentage further increased rapidly during the

days. (Figure 21)

Figure 21: Proportion of patients reporting no absence from school (score 1 of 5), less to moderate

absence from school (score 2-3 of 5) and severe absence from school (score 4-5 of 5) during six days

after surgical exposure.

When school absence is evaluated, a statistically significant difference in gender is

found the day after surgical exposure (D1) (p=0.050). The median score concerning

missing school was 3 “some” in men where it was 1 “not at all” in women. (Figure 22)

Figure 22: Boxplot reporting school absence the day after surgical exposure (School absence at D1),

the difference between men and women being statistically significant (p=0.050).

0102030405060708090100

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

noabsencefromschool

lesstomoderateabsencefromschool

severeabsencefromschool

41

When evaluating general school absence over the six days after exposure, 28.6% of

men and only 10% of women reported severe scores (score 4-5 of 5), indicating

more men were absent from school, for a longer time, than women did.

On the day of exposure (D0) 73.3% of men reported severe school absence,

whereas only 31.8% of the women did. During the next post-operative days a marked

decrease was seen in women, where from day 4 no women reported severe school

absence. (Figure 23)

Figure 23: Proportion of patients reporting school absence as severe (score 4-5 of 5) in men and

women according to day post-surgery.

According to age, 22.2% of patients younger than sixteen years old were absent from

school for a longer period when compared to the ones older than sixteen years old,

where only 12.5% did. This difference is not statistically significant (p=0.463).

School absence was reported as low (score 1-3 of 5) in 91.7% of the open group and

in 60% of the closed group. Severe school absence (score 4-5 of 5) was described in

only 8.3% of patients in the open group whereas this number was 40% of patients in

the closed group.

On the day of surgical exposure 40% in the open group and 66.7% in the closed

group reported severe absence from school. (Figure 24)

0

10

20

30

40

50

60

70

80

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

men

women

42

Figure 24: Proportion of patients reporting absence from school as severe (score 4 and 5 of 5) in open

and closed exposure group according to day post-surgery.

A significant difference was found in school absence between the open group and

closed group on the first day after surgical exposure (D1) (p=0.012) as well as on the

second day after surgical exposure (D2) (p=0.048). On the first post-operative day

(D1) a median value of 1 was found in the open group and 3.5 was found in the

closed group, indicating more school absence in the closed group than in the open

group. (Figure 25)

Figure 25: Boxplots reporting school absence on the first and second post-operative day (School

absence at D1 and D2) according to technique, namely open versus closed exposure technique, the

differences being statistically significant on both days (p=0.012 and p=0.048).

0

10

20

30

40

50

60

70

80

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

43

Overall school attendance, set as the day a patient scores 1 “not at all” or 2 “very

little” out of 5 to the question about missing school, was found in most patients after 2

days.

For the open technique, school attendance returned to normal (in more than 50% of

patients) the day after surgery while for the closed technique it returned to normal on

day 3 after exposure. (Figure 26)

No significant differences in school attendance were found between the open and

closed technique (p=0.114).

Figure 26: Proportion of patients reporting school attendance (score 1-2 of 5) in open and closed

exposure group according to day post-surgery.

As mentioned before, difficulties to perform daily activities were generally low when

patients had surgical exposure of palatally impacted canines. On the day of exposure

(D0) 35.1% of patients said not to have difficulties in performing their daily activities

where 40.5% experienced severe difficulties in daily activities. The percentage of

patients reporting severe difficulties decreased fast. On the first post-operative day

(D1) 18.9% had severe difficulties and on the second post-operative day (D2) this

was only 5.4%. (Figure 27)

0

20

40

60

80

100

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

44

Figure 27: Proportion of patients reporting no difficulties in daily activities (score 1 of 5), less to

moderate (score 2-3 of 5) and severe difficulties in daily activities (score 4-5 of 5) during six days after

surgical exposure.

When explicitly looking for severe difficulties in daily activities (score 4-5 of 5) during

the six days after exposure, it was found that on the day of surgery (D0) 44% of

patients in the open group and 33.3% of patients in the closed group reported severe

difficulties in performing their daily activities. An enormous decrease in percentages

is seen in the open group one day after exposure (D1) with the percentage lowering

to 12%. The second post-operative day (D2) severe difficulties in performing daily

activities are only reported in 16.7% of the closed group. From the third day after

surgery (D3) very low percentages were found for severe difficulties in daily activities

in both groups. (Figure 28)

Figure 28: Proportion of patients reporting ability to perform daily activities as severe (score 4 and 5 of

5) in open and closed exposure group according to day post-surgery.

0102030405060708090

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

nodif?icultiesindailyactivities

lesstomoderatedif?icultiesindailyactivities

severedif?icultiesindailyactivities

05101520253035404550

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

45

On the second day after surgical exposure (D2), a significant difference was found

between the open and closed group (p=0.040). A median score 1 was found in the

open group whereas the closed group gave a median score of 1.5, indicating that the

ability to perform daily activities was higher in the open group when compared to the

closed group. (Figure 29)

Figure 29: Boxplot reporting ability to perform daily activities the second post-operative day (Daily

activities at D2), the difference between open and closed exposure technique being statistically

significant (p=0.040).

Several patients in the open and closed exposure group also complained about

difficulties eating food. On the day of surgery (D0) 48% of patients in the open group

complained about severe difficulties eating food, as did 58.3% in the closed group.

Fortunately, this impairment decreased rapidly from the first post-operative day.

(Figure 30)

Figure 30: Proportion of patients reporting ability to eat food as severe (score 4-5 of 5) in open and

closed exposure group according to day post-surgery.

0

10

20

30

40

50

60

70

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

open

closed

46

However, no statistical significant differences were found nor between both

techniques nor in gender.

When comparing unilateral versus bilateral exposure of palatally impacted canines,

statistically significant differences concerning ability to eat food were found on the

second post-operative day (D2) until the sixth post-operative day (D6). Median

values are shown in table 4 below. Patients with unilateral exposure had significantly

less difficulties to eat their food than did the ones who had bilateral exposure.

Unilateralmedianvalue

Bilateralmedianvalue

Statist.Sign.

Day 2 2 3.5 p=0.021Day 3 1 3.5 p=0.004Day 4 1 2.5 p=0.018Day 5 1 2 p=0.013Day 6 1 2 p=0.014 Table 4: median values concerning ability to eat food when comparing unilateral versus bilateral

exposure, differences being statistically significant.

47

3.5 Six months post-operative

Six months after exposure of their palatally impacted canine, 12 patients were able to

fill in the questionnaire again.

Of these 12 patients, 10 were in the open group and 2 in the closed group.

When looking at gender, 9 patients were female and 3 patients were male.

The exposure was unilateral in 10 patients and bilateral in 2 patients.

In the results of these questionnaires no significant differences were found regarding

pain, bleeding, swallowing, school absence and ability to perform ones daily activities

in gender, technique nor in unilateral or bilateral exposure.

When, six months after exposure, the question was asked if the patients were able to

eat anything they liked, a significant difference was found between both techniques

(p=0.001). In the open exposure group a median value of 1 was found, whereas in

the closed group 2.5 was found as median value. However, when these results are

interpreted it must be pointed out that there were only two patients in the closed

group. In the open group, all 10 patients gave a score 1 “not at all’, whereas in the

closed group one patient gave score 2 “very little” and the other gave score 3 “some”.

The scores 4 “quite a lot” and 5 “very much” were not given. (Figure 31)

Figure 31: Boxplot reporting ability to eat food six months after exposure when comparing open and

closed techniques, the difference being statistically significant (p=0.001).

48

When exploring the medication consumption in patients six months after exposure, it

was found that none of the patients needed analgesics or any other form of

medication at this point.

In conclusion it can be stated that six months after exposure all patients, whether

they were in the open or closed group, were completely healed.

49

4. Discussion

Regardless of the surgical method used to expose a palatally impacted canine, it is

reasonable to assume that it will have a profound influence on several aspects of

HRQOL.

This study was designed to evaluate patients’ perceptions in the immediate post-

operative days after exposure of palatally impacted canines treated by two different

surgical methods: open exposure technique or closed exposure technique.

The statistically significant longer mean duration of surgical exposure in the closed

group was not a surprising finding. The need to raise a wide flap and the additional

time to bond an attachment will result in a prolonged surgery time. This conclusion

was found by Gharaibeh and Al-Nimri in 2008 (50) and by Pearson et al. (49) as well.

In contrast, the prospective cohort study including 60 patients treated with open or

closed technique carried out by Chaushu et al. in 2005 (41) reported longer mean

operating times than this present study, especially in the open group (closed:

36.4min; SD, 17.3min; open: 44.6min; SD, 15.2min). However, their participants had

a range of different impacted teeth, not only restricted to palatally impacted canines.

Wide variations exist in the average surgical duration time for open and closed

exposure techniques. This could be attributed to differences in skill level of the

surgeon, variations in performing the surgical techniques and whether the surgery is

done with either general or local anesthesia.

Perception of pain intensity is subjective and is influenced by many factors such as

anxiety levels and motivational attitude (51). As a consequence of the oral health of

most participants in this present study being good to excellent, patients’ experience

with general dentistry was little to none, which could contribute to the range of

experienced pain and discomfort.

On the 5th post-operative day a significant difference in pain level was found between

the open and closed exposure technique. For the open group a mean pain score of 2

on a scale of 5 was given, whereas for the closed group a mean pain score of 1 was

found. This difference in mean pain scores between both groups was small, yet

indicating the closed technique as a less painful technique. Therefore, to prove that

in general the closed technique would be less painful when compared to the open

technique, a larger study with more patients should be conducted.

50

In contrast, the study of Parkin et al. in 2012 (48) and Gharaibeh and Al-Nimri in

2008 (50) showed there were no significant differences in pain during the first week

after surgical exposure with either of the two techniques. In their study it appears that

both techniques are acceptable.

In this study percentages concerning severe pain the first post-operative day, 28% in

the open and 25% in the closed group were found. These findings are similar to the

study of Gharaibeh and Al-Nimri in 2008 (50), where 33% and 22% of patients

reported severe pain on the first post-operative day in the closed and open group

respectively and also to the 27,6% and 30% reported in the Chaushu et al. (41)

study.

A decrease in severe pain was also found in the open group, ranging from 52% the

day of exposure to 28% the first post-operative day and 12% on the second day after

surgery. Lower percentages were not found.

The percentages of patients reporting severe pain in the open group was reduced to

6% the second post-operative day in the study of Gharaibeh and Al-Nimri in 2008

(50), whereas it took until the sixth post-operative day for the open group in Chaushu

et al. (41) to reach a similar reduction.

In the closed group no patients in the study of Gharaibeh and Al-Nimri in 2008 (50)

reported severe pain on day two after surgery, whereas for the closed group in the

Chaushu et al. (41) study it took until the fourth post-operative day for severe pain to

disappear. Regarding the closed group, the present results indicate that severe pain

disappeared completely on the 5th day after surgery.

Although the studies of Scheurer et al. (52) and Kvam et al. (53) have described that

girls report more pain and discomfort than do boys, the present results showed no

major gender differences in experienced pain and discomfort.

As expected, pain is evident in the immediate post-operative period. In the present

study 81 % required analgesics, which is a similar proportion to the study of Chaushu

et al. (54,55) who found that 80% of patients undergoing open exposure required

analgesia in the first 24 hours compared with 76% of patients undergoing closed

exposure technique. However, it was determined that after surgical exposure almost

all maxillofacial surgeons provide their patients with analgesics to take home.

51

Chaushu et al. 2005 (41) also found that there was a decreased need for analgesics

in the closed group after day 2. In the present study a decrease in analgesic use was

already found the day after surgery. The closed technique group was 50% analgesic

free and in the open group it was 35% on that day.

It is obvious that the use of analgesics and having pain are very closely related to

each other. When patients have moderate pain the percentages of analgesic use will

be lower than when patients are in severe pain. In figure 32 and figure 33 this close

relationship is demonstrated.

As seen in figure 32, 94.6% of patients reported pain the day of surgical exposure

(D0) and 83.3% reported to use analgesics. On day six after surgical exposure (D6)

51.4% of patients reported pain where only 22.9% used analgesics.

Of the 83.3% patients that used analgesics on the day of surgical exposure only

45.9% reported to have severe pain (score 4-5 of 5). On the sixth post-operative day

the use of analgesics decreased to 22.9% and only 14.5% of patients reported

severe pain. (Figure 33)

Figure 32: The proportion of patients reporting pain (score 2-5 of 5) and taking analgesics according to

day post-surgery.

0102030405060708090100

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

pain

analgesics

52

Figure 33: The proportion of patients reporting pain as severe (score 4-5 of 5) and taking analgesics

according to day post-surgery.

With the exception of the first post-operative day, this study showed no significant

differences concerning bleeding during the six days follow up after exposure. On the

first post-operative day, the closed eruption group scored significantly higher when

evaluating bleeding that the open eruption group did. A possible explanation could be

that in the open eruption group a periodontal pack is used to maintain the window

made in surgery and to stop the bleeding.

A significant difference in bleeding the day of surgery, a significantly longer duration

time and a significant difference in pain the 4th, 5th and 6th day after surgery was

found when comparing unilateral and bilateral exposure. It is obvious that in the

bilateral group more time is needed to expose the canines and more bleeding is

found, since the operation is more elaborate in comparison to the unilateral group.

In the study of Chaushu et al. in 2004 (55), 80% of participants in the open exposure

group reported difficulties eating and enjoying food, which might be due to the open

exposure site healing. The participants of the closed group reported a smaller impact

on eating (54). In comparison, this study found no differences between open and

closed techniques regarding eating and enjoying food. However when unilateral

exposure and bilateral exposure are compared, the ability to eat hard food is more

difficult in the bilateral group from the second day after surgery until the sixth day

after surgery.

0

10

20

30

40

50

60

70

80

90

D0 D1 D2 D3 D4 D5 D6

%Patients

Days

severepain

analgesics

53

In this study a significant difference was found in school absence between boys and

girls. On the first post-operative day, boys missed school about three times as much

as did the girls. One might be tempted to speculate that boys would like to stay home

from school more than do girls. When comparing the open exposure group and

closed exposure group, a significant difference in school absence was found the first

and second post-operative day. On these days patients in the closed exposure group

were more likely to miss school than did the patients in the open exposure group.

The ability to perform ones daily activities was significantly different on the second

day after exposure, with the patients in the open exposure group being more able to

perform their daily activities than did the patients in the closed exposure group.

School attendance returned to normal from day 1 after surgery in the open group and

day 3 in the closed group. These findings aren’t in accordance with Chaushu et al.

(54,55) who found that for the open and closed group most could be justifiably return

to school at day 4 after surgery.

Although Chaushu et al. (41,54,55) found a recovery time of 3 days for the closed

and 5 days for the open technique, our study found that patients should expect in

general a recovery within 3 days, indicating no difference in recovery time between

the open and closed technique. The overall reduction in recovery time may be due to

the intake of suitable analgesics and the use of mouth rinses or even antibiotics.

Six months post-operative, a significant difference in ability to eat hard food was

found between both groups. The patients in the open group were more able to eat

anything they like than the ones in the closed group did. However, only 12 patients

filled in their questionnaire after six months, making the total amount of patients to

make conclusions very small. For this reason it is advisable to include more patients

to be able to support or disagree with this finding. Until present no literature was

found concerning the healing six months after exposure.

There were no significant differences in age and gender between the two groups and

therefore this study is representative for the most common age for exposure of

palatally impacted canines. The questionnaire had previously been used in the study

of Chaushu et al. (41) and is considered to have a good reliability.

However, this study also has some limitations. It could be argued that the inclusion

criteria of this study were set very broadly.

54

A total of fifteen experienced maxillofacial surgeons participated in this study.

Therefore a relatively large confounding factor is present, because every surgeon

has a specific skill level and preferred operating style. Most surgeons might also

have a preferred technique, choosing to perform more open or closed procedures,

possibly influencing their experience with the other technique. A study depending on

only one surgeon would reduce this bias.

In this study, participants who had other procedures performed at the same time as

the surgical exposure had not been excluded. This can cause confounding as well.

For this reason, exclusion of patients who had other procedures performed at the

same time of exposure would be preferable in future studies.

The position of the palatally impacted maxillary canine probably has an influence in

post-operative outcome but unfortunately this study didn’t provide standardized

radiographs. In future studies it would be appropriate to establish standardized

criteria concerning which radiographs (CBCT,OPT,…) are needed and at what time

they should be taken, to make it possible to study this aspect.

55

5. Conclusion

Within the limits of this study, it can be concluded that:

• There was a statistically significant difference in mean duration of surgical exposure between the open and closed eruption technique.

• There were no significant differences found in perceptions of patients treated with an open or closed eruption technique.

• Although most participants reported pain, oral discomfort, school absence, inability to perform daily activities and the need for regular analgesic use, in most patients this was of short duration.

Additional and larger HRQOL studies should be conducted to understand recovery

after surgical exposure of palatally impacted canines.

Further prospective randomized studies, with more strict inclusion criteria, are

needed to make more precise conclusions concerning the final outcome of either

method of exposure.

56

6. Reference list

1. Becker A, Chaushu S. Succes rate and duration of orthodontic treatment for adult

patients with palatally impacted maxillary canines. Am J Orthod Dentofacial

Orthop 2003;124:509-514

2. Litsas G, Acar A. A Review of early displaced maxillary canines: etiology,

diagnosis and interceptive treatment. The Open Dentistry Journal 2011;5:39-47

3. Bishara SE. Clinical management of impacted maxillary canines. Semin Orthod

1998;4:87-98

4. Dewel BF. The upper cuspid: its development and impaction. Angle Orthod

1949;19:79-90

5. Van der Linden FPGM. Gebitsontwikkeling bij de mens. p 188. Bohn Stafleu van

Loghum;2010

6. Shapira Y, Kuftinec MM. Early diagnosis and interpretation of potential maxillary

canine impaction. J Am Dent Assoc 1998;129:1450-1454

7. Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial

Orthop 1992;101:159-171

8. Chaushu S, Chaushu G, Becker A. The use of panoramic to localize displaced

maxillary canines. Oral Surg Oral Med Oral Pathol Oral Radio Endod

1999;88:511-516

9. Bishara SE, Kommer DD, McNeil MH, et al. Management of impacted canines. Am

J Orthod 1976;80:173-90

10. Moyers RE. Handbook of orthodontics, second ed, Chicago: Year Book Medical,

1963:83-88

11. Jacoby H. The etiology of maxillary canine impaction. Am J Orthod 1982;84:125-

189

12. Miller BH. Influence of congenitally missing teeth on the eruption of upper canine.

Trans Br Soc Study Orthod 1963/64;50:17-24

13. Becker A, Smith P, Behar R. The incidence of anomalous lateral incisors in

relation to palatally displaced cuspids. Angle Orthod 1981;51:24-29

14. Bass TB. Observations on the misplaced upper canine tooth. Dent Pract Dent Rec

1967;18:25-33

15. Shafer WG, Hine MK, Levy BM. A textbook or oral pathology. 2nd ed. Philadelphia:

WB Saunders, 1963;51:24-29

57

16. Becker A. The orthodontic treatment of impacted teeth. United Kingdom:Martin

Dunitz;1998

17. Clarck CA. A method of ascertaining the relative position of unerupted teeth by

means of film radiographs. Proc R Soc Med Odontol Sectn 1910;3:87-90

18. Hitchin AD. The impacted maxillary canine. Dental Practitioner 1951;2:100-103

19. Gavel V, Dermaut L. The effect of tooth position on the image of unerupted

canines on panoramic radiographs. Eur J Orthod 1999;21:551-560

20. Wolf JE, Mattila K. Localization of impacted maxillary canines by panoramic

tomography. Dentomaxillofac Radiol 1979;8:85-91

21. Fox NA, Fletcher GA, Horner K. Localising maxillary canines using dental

panoramic tomography. Br Dent J 1995;179:416-420

22. Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by

extraction of the primary canines. Eur J Orthod 1988;10:283-295

23. Zasciurinskiene E, Bjerklin K, Smailiene D, Sidlauskas A, Puisys A. Initial vertival

and horizontal position of palatally impacted maxillary canine and effect on

periodontal status following surgical-ortodontic treatment. Angle orthodontist

2008;78:275-280

24. Crescini A, Nieri M, Buti J, Baccetti T, Prato G. Orthodontic and periodontal

outcomes of treated impacted maxillary canines. Angle Orthod 2007;77:571-577

25. Schmuth GPF, Freisfeld M, Köster O, Schüller H. The application of computerized

tomography (CT) in cases of impacted maxillary canines. Eur J Orthod

1992;14:296-301

26. Mah J, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial

imaging with the new dental CT. Oral Surg Oral Med Oral Pathol 2003;96:508-513

27. Williams BH. Diagnosis and prevention of maxillary cuspid impaction. Angle Ortod

1981;51:30-40

28. Sagne S, Lennartsson B, Thilander B. Transalveolar transplantation of maxillary

canines. An alternative to orthodontic treatment in adult patients. Am J Orthod

Dentofac Orthop 1996;90:149-157

29. Moss JP. The indications for the transplantation of maxillary canines in the light of

100 cases. Br J Oral Surg 1975;12:268-274

30. Thomas S, Turner SR, Sandy JR. Autotransplantation of teeth: is there a role? Br

J Orthod 1998;25(4):275-282

58

31. Kallu R, Vinckier R, Politis C, Mwalili S, Willems G. Tooth transplantations: a

descriptive retrospective study. Int J Oral Maxillofac Surg 2005;34:745-755

32. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long term study of 379

autotransplanted premolars. Part II. Tooth survival and pulp healing subsequent to

transplantation. Eur J Orthodont 1990;12:14-24

33. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treatment of palatal

impaction of maxillary canines with rapid maxillary expansion: a randomized

clinical trial. Am J Orthod Dentofac Orthop 2009;136:657–665.

34. Baccetti T. Risk indicators and interceptive treatment alternatives for palatally

displaced canines. Semin Orthod 2010;16:182–192.

35. Wes BJ, Swart RJ. De geïmpacteerde cuspidaat in de bovenkaak. Deel I. Etiologie

en diagnostiek. Ned Tijdschr Tandheelkd 1992;99:121-122

36. Parkin N, Benson PE, Thind B, Shah A. Open versus closed surgical exposure of

canine teeth that are displaced in roof of the mouth. Cochrane Database Sust Rev

2008(4):CD006966

37. Frank CA, Long M. Periodontal concerns associated with the orthodontic

treatment of impacted teeth. Am J Orthod Dentofacial Orthop 2002;121:639-649

38. Wisth PJ, Nordeval K, Boe OE. Comparison of two surgical methods in combined

surgical-orthodontic correction of impacted maxillary canines. Acta Odontol Scand

1976;34:53-57

39. Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted

teeth. Am J Orthod 1977;72:53-64

40. Iramaneerat S, Cunningham SJ, Horrocks EH. The effect of two alternative

methods of canine exposure upon subsequent duration of orthodontic treatment.

Int J of Paed Dent 1998;8:123-129

41. Chaushu S, Becker A, Zeltser R, Branski S, Vasker N, Chaushu G. Patients’

perception of recovery after exposure of impacted teeth: a comparison of closed

versus open eruption techniques. J. Oral. Maxillofacial Surg 2005;63:323-329

42. Boyd RL. Clinical assessment of injuries in orthodontic movement of impacted

teeth. II. Surgical recommendations. Am J Orthod 1984;86:407-418

43. Tegsjo U, Valerius-Olsson H, Andersson L. Periodontal conditions following

surgical exposure of unerupted maxillary canines- a long term follow-up study of

two surgical techniques. Swed Dent J 1984; 8:257-263

59

44. Di Biase DD. Mucous membrane and delayed eruption. Dent Pract Dent Res

1971;21:241-250

45. Odenrick L, Modeer T. Periodontal status following surgical-orthodontic alignment

of impacted teeth. Acta Odontol Scand 1978;36:233-236

46. Kohavi D, Zilberman Y, Becker A. Periodontal status following the alignment of

buccally ectopic maxillary canine teeth. Am J Orthod 1984;85:78-82

47. Becker A, Shpack N, Shteyer A. Attachement bonding to impacted teeth at the

time of surgical exposure. Eur J Orthod 1996;18:457-463

48. Parkin NA, Deery Ch, Smith AM, Tinsley D, Sandler J, Benson PE. No difference

in surgical outcomes between open and closed exposure of palatally displaced

maxillary canines. J Oral Maxillofac Surg 2012;70:2026-2034

49. Pearson MH, Robinson SN, Reed RT, Birnie DJ, Zaki GA. Management of

palatally impacted canines: the findings of a collaborative study. Eur J Orthod

1997;19:511-515

50. Gharaibeh TM, Al-nimri KS. Postoperative pain after surgical exposure of palatally

impacted canines:closed eruption versus open eruption, a prospective randomized

study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:339-342

51. Bergius M, Kiliaridis S, Berggren U. Pain in orthodontics. J Orthofacial Orthop

2000;61:125-137

52. Scheurer PA, Firestone AR, Burgin WB. Perception of pain as a result of

orthodontic treatment with fixed appliances. Eur J Orthod 1996;18:349-357

53. Kvam E, Gjerdet NR, Bondevik O. Traumatic ulcers and pain during orthodontic

treatment. Community Dent Oral Epidemiol 1987;15:104-107

54. Chaushu G, Becker A, Zeltser R, Branski S, Chaushu S. Patients’ perception of

recovery after exposure of impacted teeth with a closed eruption technique. Am J

Orthod Dentofacial Orthop 2004;125:690-696

55. Chaushu S, Becker A, Zeltser R, Vasker N, Chaushu G. Patients’ perception of

recovery after surgical exposure of impacted maxillary teeth treated with an open

eruption surgical-orthodontic technique. Eur J Orthod 2004;26:591-596

FACULTEIT GENEESKUNDE EN

GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 1:

Vragenlijst in te vullen door patiënt op de dag van de chirurgische ingreep en gedurende 6 dagen

erna. (Chaushu et al. 2005)

DAG 0 (DAG VAN DE INGREEP)

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185, 9000 Gent, België

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 1

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 2

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 3

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 4

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 5

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

DAG 6

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen:

1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag? ……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag? ……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag? ………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist? …………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag? ………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag? ………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag? …………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 2

Informatie-toestemmingsformulier patiënt (< 18 jaar)

Hallo,

Misschien heb je al gehoord over “ingesloten hoektanden”? Dit zijn hoektanden die niet spontaan kunnen doorbreken in de mond doordat ze te weinig plaats hebben. Vaak blijven ze onder het tandvlees zitten, soms zelf ter hoogte van het gehemelte.

Ingesloten hoektanden worden meestal geholpen bij het doorbreken door een kleine ingreep. Dit kan gedaan worden op twee verschillende manieren. Bij de ene techniek wordt een venstertje in het tandvlees gemaakt zodat de tand hierdoor zelf naar beneden kan zakken (‘open techniek”’); bij de andere techniek wordt de hoektand naar beneden getrokken met een ijzerdraadje en een beugel (‘gesloten techniek’).

In het kader van mijn opleiding orthodontie werk ik aan een onderzoek over ingesloten hoektanden.

Na een eerste klein onderzoekje werd gezien dat je in aanmerking komt voor deze studie.

Eén van beide technieken zal worden toegepast om jouw hoektand(en) vrij te leggen.

In deze studie wil ik aan de hand van vragenlijstjes peilen naar jullie comfort tijdens en kort na de ingreep.

Met de informatie die we uit deze studie zullen halen, kunnen later ook andere kinderen en jongeren worden geholpen.

Zou jij bereid zijn om deel te nemen aan dit onderzoek?

Als je akkoord gaat, mag je hieronder je naam of handtekening plaatsen. Ook je ouders zullen een papier ontvangen en ondertekenen vooraleer we van start gaan.

Alvast bedankt.

Lynn Hauspy

Assistent orthodontie UZ Gent

Ik, ………………………………………………………………, ga akkoord om deel te nemen aan de studie over het helpen doorbreken van de hoektanden met twee verschillende technieken.

Datum Handtekening

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185 9000 Gent België

Prof. Dr. G. De Pauw Afdelingshoofd Dienst Orthodontie De Pintelaan 185 9000 GENT BELGIË

FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 3 Informatie-toestemmingsformulier voor ouders van patiënt (< 18 jaar)

Beste ouder,

In het kader van mijn opleiding orthodontie werk ik aan een onderzoek omtrent ingesloten hoektanden.

Ingesloten hoektanden zijn hoektanden die omwille van plaatsgebrek niet spontaan kunnen doorbreken in de mondholte.

Ingesloten hoektanden worden behandeld door ze aan de hand van een chirurgische ingreep te stimuleren om door te breken. Dit kan gebeuren op twee verschillende manieren waarvan nog niet duidelijk is welke te verkiezen is boven de andere. Bij de ene techniek, die de open-venster-techniek wordt genoemd, wordt een venstertje in het tandvlees gemaakt, dat open blijft, zodat de tand kan doorbreken. Bij de andere techniek, die de gesloten-venster-techniek wordt genoemd, wordt de hoektand voorzien van een orthodontisch blokje waaraan een ijzerdraadje is bevestigd, waarna het venstertje terug wordt gesloten. Met een beugel wordt de hoektand via het ijzerdraadje in de mondholte getrokken.

In mijn studie wil ik, aan de hand van een vragenlijst, de patiëntenperceptie bij deze twee technieken vergelijken.

Bij uw zoon/dochter zal één van boven beschreven technieken worden toegepast en daarom komt hij/zij in aanmerking voor deze studie.

Daarom zou ik u willen vragen of uw zoon/ dochter mag deelnemen aan dit onderzoek?

Alle gegevens worden anoniem verwerkt en zullen alleen gebruikt worden in het kader van dit onderzoek.

Met de informatie die we uit deze studie zullen halen, kunnen later ook andere kinderen en jongeren worden geholpen.

Alvast bedankt.

Lynn Hauspy

Assistent in opleiding orthodontie UZ Gent

Ik, ………………………………………………………………, ga akkoord dat mijn zoon/dochter (schrappen wat niet past) deelneemt aan de studie omtrent de patiëntenperceptie bij ingesloten hoektanden.

Ik bevestig dat ik de aard en het doel en de te voorziene effecten van de studie heb begrepen.

Datum Handtekening

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185 9000 Gent België

Prof. Dr. G. De Pauw Afdelingshoofd Dienst Orthodontie De Pintelaan 185 9000 GENT BELGIË

FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 4 Informatie-toestemmingsformulier voor patiënt (> 18 jaar)

Beste,

In het kader van mijn opleiding orthodontie werk ik aan een onderzoek omtrent ingesloten hoektanden.

Ingesloten hoektanden zijn hoektanden die omwille van plaatsgebrek niet spontaan kunnen doorbreken in de mondholte.

Ingesloten hoektanden worden behandeld door ze aan de hand van een chirurgische ingreep te stimuleren om door te breken. Dit kan gebeuren op twee verschillende manieren waarvan nog niet duidelijk is welke te verkiezen is boven de andere. Bij de ene techniek, die de open-venster-techniek wordt genoemd, wordt een venstertje in het tandvlees gemaakt, dat open blijft, zodat de tand kan doorbreken. Bij de andere techniek, die de gesloten-venster-techniek wordt genoemd, wordt de hoektand voorzien van een orthodontisch blokje waaraan een ijzerdraadje is bevestigd, waarna het venstertje terug wordt gesloten. Met een beugel wordt de hoektand via het ijzerdraadje in de mondholte getrokken.

In mijn studie wil ik, aan de hand van een vragenlijst, de patiëntenperceptie bij deze twee technieken vergelijken.

Bij uw zoon/dochter zal één van boven beschreven technieken worden toegepast en daarom komt hij/zij in aanmerking voor deze studie.

Daarom zou ik u willen vragen of uw zoon/ dochter mag deelnemen aan dit onderzoek?

Alle gegevens worden anoniem verwerkt en zullen alleen gebruikt worden in het kader van dit onderzoek.

Met de informatie die we uit deze studie zullen halen, kunnen later ook andere kinderen en jongeren worden geholpen.

Alvast bedankt.

Lynn Hauspy

Assistent in opleiding orthodontie UZ Gent

Ik, ………………………………………………………………, ga akkoord omdeel te nemen aan de studie omtrent de patiëntenperceptie bij vrijleggen van ingesloten hoektanden met twee verschillende technieken.

Ik bevestig dat ik de aard en het doel en de te voorziene effecten van de studie heb begrepen.

Datum Handtekening

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185 9000 Gent België

Prof. Dr. G. De Pauw Afdelingshoofd Dienst Orthodontie De Pintelaan 185 9000 GENT BELGIË

FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 5 Onderzoek patiëntenperceptie na vrijleggen ingesloten hoektanden: Technische fiche

Patiëntennaam:

Leeftijd:

Naam chirurg:

Naam orthodontist:

Mondhygiëne: goed / matig / slecht

Hoektand: links / rechts

Techniek van vrijleggen: open / gesloten

Duurtijd ingreep:

(van eerste incisie tot laatste hechting)

OPG:

(e-mailen naar lynn.hauspy@ugent.be)

Opmerkingen:

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185 9000 Gent België

Prof. Dr. G. De Pauw Afdelingshoofd Dienst Orthodontie De Pintelaan 185 9000 GENT BELGIË

FACULTEIT GENEESKUNDE EN GEZONDHEIDSWETENSCHAPPEN

Vakgroep Tandheelkunde Dienst Kliniek voor Tand-, Mond- en Kaakziekten

Faculteit Geneeskunde en Gezondheidswetenschappen – Vakgroep Tandheelkunde De Pintelaan 185 P8, B-9000 Gent

Appendix 6: Vragenlijst in te vullen door patiënt 6 maanden na de chirurgische ingreep. (Chaushu et al. 2005)

1. Heeft u vandaag medicatie genomen om de pijn te verlichten? Zo ja, dewelke? ……………………………………………………………………………………………

Beantwoord de volgende vragen door gebruik te maken van onderstaande termen: 1=Helemaal niet/ 2=zeer weinig/ 3=weinig/ 4=redelijk veel/ 5= zeer veel

2. Is het moeilijk om te slikken vandaag?

……………

3. Is het moeilijk om je mond te openen vandaag? ……………

4. Was er voedsel die je niet kon eten vandaag?

……………

5. Heb je van je voedsel genoten vandaag? …………….

6. Was spreken moeilijk vandaag?

………………

7. Was het moeilijk om de slaap te vatten gisterenavond? ……………….

8. Heb je school/werk gemist?

…………………

9. Was het moeilijk om je dagelijkse activiteiten uit te voeren vandaag? …………………

10. Was er zwelling aanwezig vandaag?

………………….

11. Heb je vandaag ongemak/last/pijn ervaren ter hoogte van de wonde? …………………

12. Was er bloeding aanwezig vandaag?

………………..

13. Heb je je onwel gevoeld vandaag? …………………

14. Heb je een slechte smaak of een slechte geur in je mond gehad vandaag?

…………………

15. Waren vandaag enige voedselresten aanwezig in de operatiezone? …………………

Lynn Hauspy Assistent Orthodontie UZ Gent De Pintelaan 185 9000 Gent, België