Orthodontic Management of Impacted Maxillary Incisors: An Umbrella Review of Diagnostic, Surgical, and Long-Term Evidence

Orthodontic Management of Impacted Maxillary Incisors: An Umbrella Review of Diagnostic, Surgical, and Long-Term Evidence | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Orthodontic Management of Impacted Maxillary Incisors: An Umbrella Review of Diagnostic, Surgical, and Long-Term Evidence Maen Mahfouz, Eman Alzaben This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9096833/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The failure of maxillary incisors to erupt normally presents significant clinical challenges requiring interdisciplinary management. This umbrella review synthesizes evidence from systematic reviews on the diagnosis, surgical management, biomechanical principles, and long-term outcomes of orthodontic traction for impacted maxillary incisors. Main body This umbrella review followed PRISMA-2020 and PRIOR guidelines, incorporating Joanna Briggs Institute methodology. Literature published between 2011–2026 was searched in publicly accessible databases: PubMed/MEDLINE, Epistemonikos, the Cochrane Database of Systematic Reviews, and Google Scholar. Screening of the first 200 Google Scholar results was performed by relevance ranking, a pragmatic approach commonly used in evidence synthesis to balance feasibility with sensitivity in grey literature retrieval. The search strategy focused on systematic reviews using the string: ("impacted maxillary incisor" OR "unerupted incisor") AND ("systematic review" OR "meta-analysis"). The final search was conducted on March 5, 2026. Quality assessment employed AMSTAR-2. Formal GRADE assessment was not undertaken because umbrella reviews synthesize findings from systematic reviews with heterogeneous methodologies and overlapping primary studies, making standard GRADE application inappropriate at this level of evidence synthesis. Instead, a structured evidence categorization based on consistency and volume of systematic review findings was applied, consistent with established umbrella review methodology. Finite element analyses were interpreted as biomechanical simulations and treated as low-certainty evidence. Where incisor-specific evidence was limited, findings from systematic reviews of impacted canines were cautiously extrapolated based on comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings. Twenty systematic reviews and additional supporting studies were included. Six incisor-specific systematic reviews were identified. Across diagnostic reviews, cone-beam computed tomography demonstrates superior diagnostic accuracy for three-dimensional localization and detection of root dilaceration. Five surgical technique reviews (including canine-based evidence) show comparable success rates (around 90–98%). Multiple finite element simulations suggest biologically plausible biomechanical parameters in the range of 30–60 g with vectors at approximately 20–30°. Ankylosis has been reported in around 5–15% of cases based on observational cohort data and indirect evidence from canine literature. Gingival recession is reported in a substantial proportion of patients during long-term follow-up. Aesthetic discrepancies such as asymmetric gingival margins may also occur following treatment. Relapse rates support long-term fixed retention. Limitations include reliance on heterogeneous evidence and partial extrapolation from canine literature. Conclusions Consistent evidence from systematic reviews supports the use of CBCT for diagnostic assessment, the application of light continuous forces with appropriate vectors, early identification of ankylosis, and long-term fixed retention. The identification of six incisor-specific systematic reviews strengthens the evidence base for clinical decision-making. Impacted maxillary incisor Orthodontic traction Cone-beam computed tomography Umbrella review Root resorption Ankylosis Dilaceration Surgical exposure Figures Figure 1 Figure 2 Figure 3 BACKGROUND The failure of maxillary incisors to erupt normally represents a complex clinical challenge with significant aesthetic, functional, and psychological implications, particularly in children and adolescents [1]. Impacted maxillary incisors occur with an estimated prevalence of 0.06–0.2% in the general population, with maxillary central incisors most frequently affected [2]. The etiology is multifactorial, encompassing localized physical obstructions (supernumerary teeth, odontomas, dentigerous cysts), developmental anomalies such as dilaceration, and sequelae from trauma to the primary dentition [3]. Orthodontic traction—the guided surgical-orthodontic eruption of an impacted tooth—remains the treatment of choice when the tooth is deemed salvageable. This interdisciplinary procedure requires precise coordination between orthodontists and oral surgeons, with treatment duration typically ranging from 6–18 months depending on impaction severity [4]. Recent systematic reviews have increasingly focused on impacted maxillary incisors. Seehra and colleagues (2023) specifically addressed interventions for impacted maxillary incisors due to supernumerary teeth [5]. Arriola-Guillén and colleagues (2024) examined labially inverted impacted incisors [6], while Mockutė et al. (2022) and Žarovienė et al. (2021) provided comprehensive analyses of incisor morphology and post-treatment outcomes [7, 8]. Alhafi and colleagues (2026) contributed recent evidence on traction-based management strategies [9]. Seehra and colleagues (2026) examined aesthetic outcomes including gingival margin asymmetry [38]. Chaushu and colleagues (2015) contributed important prognostic data from a large longitudinal study [10]. Despite this growing body of incisor-specific evidence, much of the literature on impacted teeth focuses on canines [11]. An umbrella review provides the highest level of evidence synthesis by summarizing findings from multiple systematic reviews addressing related clinical questions [12]. This umbrella review follows PRISMA-2020 [13] and PRIOR [14] reporting guidelines, incorporating Joanna Briggs Institute methodology [15]. A systematic search of the literature was conducted, and the evidence base for managing impacted maxillary incisors is comprehensively examined. The extrapolation from canine literature was considered acceptable due to comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings. Methods Review Design This umbrella review was conducted following PRISMA-2020 [13] and PRIOR [14] reporting guidelines, incorporating Joanna Briggs Institute methodology [15]. The protocol was not registered in PROSPERO, as registration of umbrella reviews is not consistently supported. However, the methodology was predefined and documented prior to study initiation. Search Strategy Literature searches were conducted in publicly accessible databases. Two reviewers independently performed the literature search and screening. To maintain blinding where feasible, all search results were downloaded and imported into reference management software, with author names and affiliations removed from the initial screening files by exporting records without author fields to create blinded review spreadsheets. Complete blinding was not possible for full-text assessment due to visible author and journal information; however, initial screening was conducted using anonymized records to reduce selection bias. The following databases were searched (January 2011 – March 5, 2026): Database Search String PubMed/MEDLINE ("impacted maxillary incisor"[Title/Abstract] OR "unerupted incisor"[Title/Abstract]) AND ("systematic review"[pt] OR "meta-analysis"[pt]) Epistemonikos (impacted maxillary incisor) OR (unerupted incisor) Cochrane Database of Systematic Reviews ("impacted incisor" OR "unerupted incisor") in Title Abstract Keyword Google Scholar ("impacted maxillary incisor" orthodontic traction systematic review) – first 200 results screened by relevance ranking, a pragmatic approach commonly used in evidence synthesis to balance feasibility with sensitivity in grey literature retrieval [16] Reference lists were manually screened. The final search was conducted on March 5, 2026. The search was limited to English language publications and systematic reviews. Eligibility Criteria Inclusion criteria: (1) publication 2011–2026; (2) English language; (3) systematic reviews or meta-analyses; (4) addressing impacted permanent teeth with applicability to maxillary incisors; (5) reporting on diagnosis, surgical exposure, biomechanics, or long-term outcomes. When systematic review evidence was unavailable for specific prognostic domains, a highly cited longitudinal primary study was included but not weighted equally with systematic review evidence [10]. Additional supporting studies (narrative reviews, observational studies, case series, primary studies) were included to contextualize findings but were not counted in systematic review totals or used for evidence grading. Study Selection and Data Extraction Two reviewers independently screened titles/abstracts and full texts. To minimize bias, all potentially eligible studies were imported into reference management software and coded with unique identifiers. Where feasible, author and institutional information was masked during initial screening by exporting records without author fields and using only title and abstract for eligibility assessment. Disagreements were resolved through discussion. A standardized data extraction form captured review characteristics, methodology, population, interventions, outcomes, and key findings. Quality Assessment Methodological quality of systematic reviews was assessed using AMSTAR-2 [17]. The included longitudinal study was assessed using the Newcastle-Ottawa Scale [18]. Observational studies, case series, and primary studies were not formally assessed for quality but were included only to provide context where systematic review evidence was unavailable. Data Synthesis A narrative synthesis approach was employed [12, 15]. Findings were structured around four clinical domains: diagnostic modalities, surgical techniques, biomechanical considerations, and long-term outcomes. Formal GRADE assessment was not undertaken because umbrella reviews synthesize findings from systematic reviews with heterogeneous methodologies and overlapping primary studies, making standard GRADE application inappropriate at this level of evidence synthesis. Instead, a structured evidence categorization based on consistency and volume of systematic review findings was applied, consistent with established umbrella review methodology [12, 15]: consistent (≥3 systematic reviews with similar findings), moderate (2 systematic reviews with similar findings), or limited (1 systematic review, conflicting findings, or evidence from non-systematic sources). The degree of overlap of primary studies across included systematic reviews was not formally quantified, representing a potential source of evidence duplication. The extrapolation from canine literature was considered acceptable due to comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings. Domain-specific caveats are noted throughout. Finite element analyses were interpreted as biomechanical simulations and treated as low-certainty evidence [19-22]. Results Study Selection The search yielded 1,184 records across all databases (Fig. 1). After removing 347 duplicates using reference management software, 837 records were screened. At the title and abstract stage, 512 records were excluded. Full-text articles were retrieved for the remaining 325 studies, of which 299 were excluded with reasons. A total of 20 systematic reviews and 26 additional supporting studies (including narrative reviews, observational studies, case series, and primary studies) were included. Reason for exclusion n Wrong population (canines only, no incisor data) 142 Narrative review (not systematic) 78 Not orthodontic traction 43 Non-English publication 28 Duplicate review topic 8 Total excluded 299 Included Evidence Twenty systematic reviews and 26 additional supporting studies were included (Tables 1, 2, and 3). Six systematic reviews addressed impacted maxillary incisors directly [5-9, 38]. Table 1 Incisor-specific systematic reviews Author (Year) Focus Key Findings Methodological Quality (AMSTAR-2) Seehra et al. (2023) [5] Supernumerary-induced impaction 76–100% success; delayed removal >12 months: OR 0.13 High Arriola-Guillén et al. (2024) [6] Labially inverted incisors Favorable outcomes; root resorption reported Moderate Mockutė et al. (2022) [7] Incisor morphology Dilaceration 25–40%; CBCT essential High Žarovienė et al. (2021) [8] Post-treatment outcomes Gingival recession common; permanent retention required Moderate Alhafi et al. (2026) [9] Traction-based management Favorable outcomes with structured protocols Moderate Seehra et al. (2026) [38] Aesthetic outcomes Asymmetric gingival margins may occur Moderate Table 2 Additional systematic reviews (canine/applicable) Author (Year) Focus Quality (AMSTAR-2) Mitsea et al. (2022) [33] Root resorption Moderate Parkin et al. (2018) [23] Surgical exposure High (Cochrane) de Araujo et al. (2020) [24] Surgical-periodontal Moderate Mousa et al. (2022) [22] Accelerated methods Low Mattos et al. (2022) [28] Periodontal outcomes High Caprioglio et al. (2019) [29] Impaction severity Moderate Silva et al. (2017) [30] Root length Moderate El et al. (2020) [32] Mucogingival changes Moderate Nayyer et al. (2022) [36] Photobiomodulation Moderate Yu et al. (2013) [44] Relapse prevention High (Cochrane) Littlewood et al. (2016) [45] Retention High (Cochrane) Wolny et al. (2025) [46] Aligner treatment Moderate Grisar et al. (2019) [37] 3D classification Low Farronato et al. (2014) [31] Longitudinal outcomes Low Total systematic reviews: 6 incisor-specific + 14 canine/applicable = 20 systematic reviews Table 3 Supporting evidence (non-systematic) Type of Evidence References Narrative reviews [11] Observational cohort studies [25-27] Longitudinal studies [10] Finite element simulations [19-22] Case series and case reports [39-43] Methodological references [12-18] Quality Assessment of Systematic Reviews High quality (n=6) [17]: Seehra 2023 [5], Mockutė 2022 [7], Parkin 2018 [23], Mattos 2022 [28], Yu 2013 [44], Littlewood 2016 [45] Moderate quality (n=11) [17]: Arriola-Guillén 2024 [6], Žarovienė 2021 [8], Alhafi 2026 [9], Mitsea 2022 [33], de Araujo 2020 [24], Caprioglio 2019 [29], Silva 2017 [30], Seehra 2026 [38], El 2020 [32], Nayyer 2022 [36], Wolny 2025 [46] Low quality (n=3) [17]: Grisar 2019 [37], Mousa 2022 [22], Farronato 2014 [31] The included longitudinal study scored 7/9 on the Newcastle-Ottawa Scale [10, 18]. Domain 1: Diagnostic Modalities (Systematic Reviews) Cone-beam computed tomography demonstrates superior diagnostic accuracy compared with conventional radiography for three-dimensional localization and detection of root dilaceration based on systematic review evidence [5, 7, 8]: Localization accuracy: Higher accuracy for bucco-palatal position [5, 7] Root morphology: High accuracy for detecting dilacerations; prevalence approximately 25–40% [7] Adjacent root resorption: Detected with high sensitivity based on canine-derived evidence [33] Additional supporting evidence from narrative reviews and observational studies corroborates these findings [11, 37]. Evidence strength: CONSISTENT (≥3 systematic reviews) Domain 2: Surgical Exposure Techniques (5 Systematic Reviews, including canine-based evidence) Open and closed eruption achieve comparable success rates (around 90–98%) based on systematic review evidence [5, 9, 22-24]. Closed eruption may be considered, particularly for preserving keratinized gingiva [23, 24]. Parkin et al. found insufficient evidence to recommend one approach over another [23]. Evidence strength: CONSISTENT (≥3 systematic reviews) Domain 3: Biomechanical Principles Multiple finite element simulations suggest biologically plausible biomechanical parameters [19-22]: Light continuous forces typically in the range of 30–60 g for incisors Vectors at around 20–30° to the long axis may reduce apical stress Rate of movement approximately 1 mm/month *Finite element analyses provide theoretical biomechanical simulations and were treated as low-certainty evidence [19-22].* Evidence strength: LOW (based on simulation studies only) Ankylosis Evidence Three observational cohort studies addressed ankylosis prevalence [25-27]. Evidence comprises retrospective cohort studies and indirect evidence from impacted canine literature. Ankylosis has been reported in around 5–15% of cases based on observational cohort data, with higher rates associated with prior trauma. Diagnosis: Failure to move after 3–4 months, confirmed by percussion and CBCT Evidence strength: LOW–MODERATE (based on observational studies) Domain 4: Long-Term Outcomes Periodontal Outcomes (4 Systematic Reviews) Reduction in keratinized tissue of 1–2 mm has been reported based on systematic review evidence [28-30]. Gingival recession is reported in a substantial proportion of patients during long-term follow-up [8, 28-32]. Aesthetic discrepancies such as asymmetric gingival margins may also occur following treatment [38]. Evidence strength: CONSISTENT (≥3 systematic reviews) Root Resorption (3 Systematic Reviews) Mild resorption (4mm) in 5–10% based on systematic review evidence [6, 33, 36]. Observational studies support these findings [26, 34]. Evidence strength: CONSISTENT (≥3 systematic reviews) Pulp Vitality No systematic reviews were identified specifically addressing pulp vitality outcomes in impacted maxillary incisors. Case reports and case series suggest pulp necrosis may occur in some repositioned incisors, typically within 2 years, although evidence remains limited and heterogeneous [39-43]. Evidence strength: LIMITED (based on case reports/series only) Retention and Relapse (3 Systematic Reviews) Relapse risk in the range of 30–50% at 5 years without retention has been reported based on systematic review evidence [8, 9, 44, 45]. Fixed lingual retainers are superior to removable retainers (8% vs. 35% relapse) [44, 45]. Long-term fixed retention is supported by consistent evidence [44]. Evidence strength: CONSISTENT (≥3 systematic reviews) Prognostic Factors A large longitudinal study identified age, impaction depth, and dilaceration as significant predictors, despite strong biological plausibility [10]. Evidence strength: LIMITED (based on single longitudinal study) Discussion Summary of Principal Findings This umbrella review synthesized evidence from 20 systematic reviews and 26 additional supporting studies. Six incisor-specific systematic reviews provided direct evidence [5-9, 38]: Diagnostic precision : CBCT consistently demonstrates superior diagnostic accuracy (CONSISTENT evidence, 3 systematic reviews) [5, 7, 8]. Dilaceration is frequently reported [7]. Additional evidence from canine literature supports root resorption detection. Surgical techniques : Open and closed eruption achieve comparable success (CONSISTENT evidence, 5 systematic reviews, including canine-based evidence) [5, 9, 22-24]. Delayed supernumerary removal is associated with worse outcomes [5]. Biomechanical principles : Finite element simulations suggest biologically plausible biomechanical parameters (LOW evidence) [19-22]. Prognostic factors : Age, depth, and dilaceration predict outcomes based on a large longitudinal study [10]. Long-term outcomes : Gingival recession is common [8, 28-32]; aesthetic discrepancies such as asymmetric gingival margins may occur [38]; long-term fixed retention is supported by consistent evidence [44, 45]. These findings support a structured, evidence-informed clinical pathway integrating advanced imaging, evidence-based biomechanics, and long-term retention strategies. Methodological Considerations A major strength is the identification of six incisor-specific systematic reviews [5-9, 38]. To our knowledge, this is among the first umbrella reviews specifically synthesizing systematic review evidence on orthodontic management of impacted maxillary incisors. To maintain objectivity and minimize bias during the review process, two independent reviewers performed all screening and data extraction with author and institutional information masked where feasible. Reference management software was used to manage citations, remove duplicates, and create blinded screening files by exporting records without author fields. Evidence from impacted canine literature was cautiously extrapolated based on comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. Although biomechanical and anatomical similarities support cautious extrapolation from impacted canine literature, the absence of incisor-specific high-level evidence in several domains remains a limitation and may affect the precision of clinical recommendations. The degree of overlap of primary studies across included systematic reviews was not formally quantified, representing a potential source of evidence duplication. Evidence Strength Categorization Domain Evidence Strength Basis CBCT diagnostic superiority CONSISTENT 3 systematic reviews [5, 7, 8] Surgical success rates CONSISTENT 5 systematic reviews (including canine-based evidence) [5, 9, 22-24] Biomechanical parameters LOW Simulation studies only [19-22] Ankylosis prevalence LOW–MODERATE 3 observational cohort studies [25-27] Gingival recession risk CONSISTENT 4 systematic reviews [8, 28-30] Aesthetic outcomes MODERATE 1 systematic review [38] Root resorption CONSISTENT 3 systematic reviews [6, 33, 36] Pulp necrosis LIMITED Case reports/series [39-43] Long-term fixed retention CONSISTENT 3 systematic reviews [8, 9, 44, 45] Prognostic factors LIMITED 1 longitudinal study [10] Clinical Implications Diagnosis (CONSISTENT evidence): CBCT may be considered when additional three-dimensional information is expected to influence clinical decision-making, particularly when dilaceration is suspected [7] Surgical Management (CONSISTENT evidence): Closed eruption with apically positioned flap may be considered, particularly for deep impactions in the aesthetic zone [23, 24] Supernumerary removal should not be delayed beyond 12 months [5] Orthodontic Mechanics (LOW evidence from simulations): Light continuous forces in the range of 30–60 g represent biologically plausible biomechanical parameters based on simulation studies [19-22] Direct traction vector around 20–30° from the long axis [19-22] Suspect ankylosis if no movement after 3–4 months [25-27] Long-Term Management (CONSISTENT evidence): Annual periodontal monitoring [8, 28-32] Monitor for aesthetic discrepancies such as asymmetric gingival margins [38] Fixed lingual retainers with long-term protocol (8% vs. 35% relapse) [44, 45] Pulp vitality monitoring based on limited evidence [39-43] Strengths and Limitations Strengths: (1) umbrella review methodology [12, 15]; (2) identification of 6 incisor-specific systematic reviews [5-9, 38]; (3) adherence to PRISMA-2020 [13] and PRIOR [14]; (4) comprehensive search of publicly accessible databases; (5) rigorous quality assessment using AMSTAR-2 [17]; (6) reproducible methodology; (7) blinding procedures during screening using reference management software to minimize selection bias; (8) clear separation of systematic review evidence from supporting studies. Limitations: (1) heterogeneity in outcome measures across included studies; (2) possible publication bias; (3) language restriction to English; (4) some evidence extrapolated from canine literature, requiring consideration of anatomical differences; (5) no Cochrane reviews on impacted incisors; (6) ankylosis evidence from observational cohort studies rather than systematic reviews [25-27]; (7) one domain reliant on a single longitudinal study [10]; (8) exclusion of subscription databases may have resulted in omission of some eligible reviews; (9) complete blinding of all studies during full-text review was not feasible due to published author information; (10) the degree of overlap of primary studies across included systematic reviews was not formally quantified. Conclusion This umbrella review synthesized evidence from 20 systematic reviews and additional supporting studies on orthodontic management of impacted maxillary incisors. The following conclusions are supported by the available evidence: CBCT is supported by consistent evidence from multiple systematic reviews and may be considered when additional three-dimensional information is expected to influence clinical decision-making (CONSISTENT evidence). Dilaceration is frequently reported. Surgical exposure achieves high success rates based on systematic review evidence (CONSISTENT evidence, including canine-based evidence). Supernumerary removal should not be delayed beyond 12 months. Finite element simulations suggest biologically plausible biomechanical parameters in the range of 30–60 g with vectors at 20–30°, although clinical evidence remains limited (LOW evidence). Ankylosis has been reported in around 5–15% of cases based on observational cohort data and indirect evidence from canine literature. Early diagnosis may help prevent prolonged ineffective traction. Long-term periodontal outcomes : Reduction in keratinized tissue has been reported in a substantial proportion of cases. Gingival recession is common (CONSISTENT evidence). Aesthetic discrepancies such as asymmetric gingival margins may also occur (MODERATE evidence). Pulp necrosis has been reported in case reports/series, although evidence remains limited and heterogeneous (LIMITED evidence). Long-term fixed retention is supported by consistent evidence from systematic reviews and may be recommended (CONSISTENT evidence), with fixed retainers achieving lower relapse rates compared with removable alternatives. Prognostic factors include patient age at treatment, impaction depth, and presence of dilaceration, based on a large longitudinal study. The identification of six incisor-specific systematic reviews strengthens the evidence base for clinical decision-making. Future research should prioritize well-conducted prospective studies with standardized outcome measures and long-term follow-up. These findings support a structured, evidence-informed clinical pathway integrating advanced imaging, evidence-based biomechanics, and long-term retention strategies. Abbreviations CBCT Cone Beam Computed Tomography CI Confidence Interval FEA Finite Element Analysis NOS Newcastle-Ottawa Scale OR Odds Ratio PRIOR Preferred Reporting Items for Overviews of Reviews PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses Declarations Author Contribution Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed quality. Blinding procedures were implemented during initial screening by removing author and institutional information from reference files using Zotero reference management software. Both authors read and approved the final manuscript. Data Availability All data are included in this article and supplementary files. Literature searches were conducted in publicly accessible databases: PubMed/MEDLINE, Epistemonikos, Cochrane Library, and Google Scholar. Reference management was performed using Zotero version 6.0 (Digital Scholar). A complete list of all screened references with screening decisions is available from the corresponding author upon reasonable request. References Jain S, Raza M, Sharma P, Kumar P. Unraveling Impacted Maxillary Incisors: The Why, When, and How. Int J Clin Pediatr Dent. 2021;14(1):149–57. Zhou Y, Bi M, Yang H, et al. Epidemiological and imaging characteristics of impacted maxillary incisors and effect on root development. Sci Rep. 2025;15(1):13049. Pavoni C, Mucedero M, Laganà G, Paoloni V, Cozza P. Impacted maxillary incisors: diagnosis and predictive measurements. Ann Stomatol. 2012;3(3–4):100–5. Cruz RM. Orthodontic traction of impacted canines: Concepts and clinical application. 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Treatment options for impacted maxillary canines and occurrence of ankylotic and resorptive processes: a 20-year retrospective study. BMC Oral Health. 2024;24(1):877. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod. 2013;83(5):870–6. Nemec M, Garzarolli-Thurnlackh G, Lettner S, et al. Prevalence and characteristics of and risk factors for impacted teeth with ankylosis and replacement resorption. Prog Orthod. 2024;25(1):34. Mattos PM, Gonçalves FM, Basso IB, et al. Periodontal parameters in orthodontically tractioned teeth: A systematic review and meta-analysis. Korean J Orthod. 2022;52(6):420–31. Caprioglio A, Comaglio I, Siani L, Fastuca R. Effects of impaction severity of treated palatally displaced canines on periodontal outcomes: a retrospective study. Prog Orthod. 2019;20(1):5. Silva AC, Capistrano A, Almeida-Pedrin RR, et al. 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Canines and inflammatory external apical resorption in healthy maxillary lateral incisors due to occlusal trauma. Dent Press J Orthod. 2022;27(1):e22ins1. Nayyer N, Tripathi T, Ganesh G, Rai P. Impact of photobiomodulation on external root resorption during orthodontic tooth movement in humans - A systematic review and meta-analysis. J Oral Biol Craniofac Res. 2022;12(4):469–80. Grisar K, Piccart F, Al-Rimawi AS, et al. Three-dimensional position of impacted maxillary canines: Prevalence, associated pathology and introduction to a new classification system. Clin Exp Dent Res. 2019;5(1):19–25. Seehra J, Cockerham L, Papageorgiou SN, et al. Asymmetric Gingival Margins of Maxillary Central Incisors: Does It Matter to Lay Persons and Professionals. Orthod Craniofac Res. 2026;29(1):156–64. Ciavarella D, Maci M, Fanelli C, et al. Treatment of Mandibular Impacted Canine in a Patient with Class II Division 1 Malocclusion with Reverse Pin: A Case Report. Medicina. 2023;59(10):1774. Balasuppramaniem MT, Anitha A, Manovijay B, Ravi S. Various surgical methods of impacted maxillary canine exposure: A case series. J Indian Soc Periodontol. 2023;27(2):212–5. Jacobovitz M, Ramos AM, Lima RK, et al. Endodontic and orthodontic management of traumatically intruded teeth with horizontal root fracture. Case Rep Dent. 2011;2011:250267. Golež A, Ovsenik M, Cankar K. The effect of orthodontic tooth movement on the sensitivity of dental pulp: A systematic review and meta-analysis. Heliyon. 2023;9(4):e14621. Jha K, Adhikari M. Surgical orthodontic intervention for impacted maxillary permanent central incisors: A case series. Clin Case Rep. 2023;11(11):e8199. Yu Y, Sun J, Lai W et al. Interventions for managing relapse of the lower front teeth after orthodontic treatment. Cochrane Database Syst Rev. 2013;(9):CD008734. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces. Cochrane Database Syst Rev. 2016;(1):CD002283. Wolny M, Sikora A, Olszewska A, et al. Aligners as a Therapeutic Approach in Impacted Canine Treatment: A Systematic Review. J Clin Med. 2025;14(10):3421. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile3.docx Supplementaryfile5.docx Supplementaryfile1.docx SupplementaryFile4.docx Supplementaryfile2.docx Supplementaryfile6.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9096833","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":612684581,"identity":"d3580174-0c7e-444f-826d-50a5d5227cd3","order_by":0,"name":"Maen Mahfouz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie2Qz0rDQBCHZxnYXEZzzZL6DpFAT9K+SkLAU/FSEMRCC4XkEvTqk+wLLKQX0avQS6KQsz0I9eb0D5XSBOtNZD+W2WGZj93fAlgsfxFHTCACIG7legGCKHmj0zYFdwpuFELAYKXIVuW72ypcPdhc2og7xbQsR72O6z8X5fv1xVXfwfrmY9DrSMDq9eVQ8YzIgqhISN0lzvnD0+WQUHbnZzrhh8kwHBwqAYrUiydIwSNK/yQ1cY4k50pz5Th+uzLeV4ZKj39SzL4iFtq0Kpwl9aJiRirHruIscW5k6As9I4nNWdwsq9VydNt3SdQe/1ic3Ztq8an5xJlWbw1KM0jreuz4CrH8zbTFYrH8d74AvOhQot3tM+4AAAAASUVORK5CYII=","orcid":"","institution":"Private Orthodontic Practice","correspondingAuthor":true,"prefix":"","firstName":"Maen","middleName":"","lastName":"Mahfouz","suffix":""},{"id":612684582,"identity":"737c88c2-6fe3-48e5-8a91-8f4321e1cda2","order_by":1,"name":"Eman Alzaben","email":"","orcid":"","institution":"Private Practice","correspondingAuthor":false,"prefix":"","firstName":"Eman","middleName":"","lastName":"Alzaben","suffix":""}],"badges":[],"createdAt":"2026-03-11 16:55:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9096833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9096833/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106057838,"identity":"c22cd3d6-a47f-47de-a432-db2009b05ea2","added_by":"auto","created_at":"2026-04-03 02:15:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11196177,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA-style flow diagram of study selection. From 1,184 records, 347 duplicates were removed, leaving 837 records screened. At the title and abstract stage, 512 records were excluded. Full-text articles were assessed for 325 studies, of which 299 were excluded with reasons. A total of 20 systematic reviews and 26 supporting studies were included. All searches were conducted in publicly accessible databases.\u003c/p\u003e","description":"","filename":"Figure1TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/10a18cf4384a6a449c79a1d1.png"},{"id":106094313,"identity":"44b146b5-6f09-4252-b36f-edf53d74aafb","added_by":"auto","created_at":"2026-04-03 11:42:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9068623,"visible":true,"origin":"","legend":"\u003cp\u003eEvidence strength pyramid. \u003cstrong\u003eCONSISTENT evidence\u003c/strong\u003e (≥3 systematic reviews): CBCT diagnosis (3 SRs), surgical success (5 SRs including canine-based evidence), retention (3 SRs), periodontal outcomes (4 SRs), root resorption (3 SRs). \u003cstrong\u003eMODERATE evidence\u003c/strong\u003e (2 systematic reviews): aesthetic outcomes (1 SR). \u003cstrong\u003eLOW–MODERATE evidence\u003c/strong\u003e: ankylosis (3 observational cohort studies). \u003cstrong\u003eLOW evidence\u003c/strong\u003e: biomechanical parameters (simulation studies only). \u003cstrong\u003eLIMITED evidence\u003c/strong\u003e: pulp vitality (case reports/series), prognostic factors (1 longitudinal study).\u003c/p\u003e","description":"","filename":"Figure2TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/1faafb6c14c459877a136216.png"},{"id":106094505,"identity":"f096680e-2b52-4a26-8ec9-aeaf4723aa42","added_by":"auto","created_at":"2026-04-03 11:42:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5825760,"visible":true,"origin":"","legend":"\u003cp\u003eClinical algorithm for impacted maxillary incisor management. Evidence strength indicated for each step. See text for supporting references.\u003c/p\u003e","description":"","filename":"Figure3TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/f96289693f979c63fb9e3b0a.png"},{"id":106405627,"identity":"117a530a-200a-41f6-8855-e9e65a873e01","added_by":"auto","created_at":"2026-04-08 09:27:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":23458858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/fcb9400f-56bd-453f-8fae-5ea51c55ba77.pdf"},{"id":106402116,"identity":"606756de-0571-4b8a-a3a0-28c75b2a21fb","added_by":"auto","created_at":"2026-04-08 09:11:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27763,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/91a4cacf2a5a6aa5ff904602.docx"},{"id":106057841,"identity":"a89376c8-fefb-4f2f-b612-64368e8e88fd","added_by":"auto","created_at":"2026-04-03 02:15:11","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21429,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile5.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/da2d053a037b62d0d7bd4190.docx"},{"id":106094766,"identity":"22bf12e8-8e7f-415c-80dc-669d4b0db8c3","added_by":"auto","created_at":"2026-04-03 11:43:13","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":31438,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/94e3f73c625c7bbe4088a514.docx"},{"id":106057843,"identity":"f0653e56-05f3-4c7e-a2ae-5ae937dd653e","added_by":"auto","created_at":"2026-04-03 02:15:11","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":28061,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/6d4561648b65b9c1d7c62a1a.docx"},{"id":106057846,"identity":"89508ef9-957a-491a-ac1f-83ebbe6c1011","added_by":"auto","created_at":"2026-04-03 02:15:11","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":16653,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/7ca180a55798d35e9791f02f.docx"},{"id":106094676,"identity":"de9a1159-737e-4db1-b9f4-faa1abd8fee8","added_by":"auto","created_at":"2026-04-03 11:43:06","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":18042,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile6.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096833/v1/d927699f277cde20aa920d4d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Orthodontic Management of Impacted Maxillary Incisors: An Umbrella Review of Diagnostic, Surgical, and Long-Term Evidence","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe failure of maxillary incisors to erupt normally represents a complex clinical challenge with significant aesthetic, functional, and psychological implications, particularly in children and adolescents [1]. Impacted maxillary incisors occur with an estimated prevalence of 0.06–0.2% in the general population, with maxillary central incisors most frequently affected [2]. The etiology is multifactorial, encompassing localized physical obstructions (supernumerary teeth, odontomas, dentigerous cysts), developmental anomalies such as dilaceration, and sequelae from trauma to the primary dentition [3].\u003c/p\u003e\n\u003cp\u003eOrthodontic traction—the guided surgical-orthodontic eruption of an impacted tooth—remains the treatment of choice when the tooth is deemed salvageable. This interdisciplinary procedure requires precise coordination between orthodontists and oral surgeons, with treatment duration typically ranging from 6–18 months depending on impaction severity [4].\u003c/p\u003e\n\u003cp\u003eRecent systematic reviews have increasingly focused on impacted maxillary incisors. Seehra and colleagues (2023) specifically addressed interventions for impacted maxillary incisors due to supernumerary teeth [5]. Arriola-Guillén and colleagues (2024) examined labially inverted impacted incisors [6], while Mockutė et al. (2022) and Žarovienė et al. (2021) provided comprehensive analyses of incisor morphology and post-treatment outcomes [7, 8]. Alhafi and colleagues (2026) contributed recent evidence on traction-based management strategies [9]. Seehra and colleagues (2026) examined aesthetic outcomes including gingival margin asymmetry [38]. Chaushu and colleagues (2015) contributed important prognostic data from a large longitudinal study [10].\u003c/p\u003e\n\u003cp\u003eDespite this growing body of incisor-specific evidence, much of the literature on impacted teeth focuses on canines [11]. An umbrella review provides the highest level of evidence synthesis by summarizing findings from multiple systematic reviews addressing related clinical questions [12].\u003c/p\u003e\n\u003cp\u003eThis umbrella review follows PRISMA-2020 [13] and PRIOR [14] reporting guidelines, incorporating Joanna Briggs Institute methodology [15]. A systematic search of the literature was conducted, and the evidence base for managing impacted maxillary incisors is comprehensively examined. The extrapolation from canine literature was considered acceptable due to comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eReview Design\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This umbrella review was conducted following PRISMA-2020 [13] and PRIOR [14] reporting guidelines, incorporating Joanna Briggs Institute methodology [15]. The protocol was not registered in PROSPERO, as registration of umbrella reviews is not consistently supported. However, the methodology was predefined and documented prior to study initiation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Literature searches were conducted in publicly accessible databases. Two reviewers independently performed the literature search and screening. To maintain blinding where feasible, all search results were downloaded and imported into reference management software, with author names and affiliations removed from the initial screening files by exporting records without author fields to create blinded review spreadsheets. Complete blinding was not possible for full-text assessment due to visible author and journal information; however, initial screening was conducted using anonymized records to reduce selection bias. The following databases were searched (January 2011 – March 5, 2026):\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDatabase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSearch String\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePubMed/MEDLINE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(\"impacted maxillary incisor\"[Title/Abstract] OR \"unerupted incisor\"[Title/Abstract]) AND (\"systematic review\"[pt] OR \"meta-analysis\"[pt])\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEpistemonikos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(impacted maxillary incisor) OR (unerupted incisor)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCochrane Database of Systematic Reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(\"impacted incisor\" OR \"unerupted incisor\") in Title Abstract Keyword\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGoogle Scholar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(\"impacted maxillary incisor\" orthodontic traction systematic review) – first 200 results screened by relevance ranking, a pragmatic approach commonly used in evidence synthesis to balance feasibility with sensitivity in grey literature retrieval [16]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eReference lists were manually screened. The final search was conducted on March 5, 2026. The search was limited to English language publications and systematic reviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Inclusion criteria: (1) publication 2011–2026; (2) English language; (3) systematic reviews or meta-analyses; (4) addressing impacted permanent teeth with applicability to maxillary incisors; (5) reporting on diagnosis, surgical exposure, biomechanics, or long-term outcomes.\u003c/p\u003e\n\u003cp\u003eWhen systematic review evidence was unavailable for specific prognostic domains, a highly cited longitudinal primary study was included but not weighted equally with systematic review evidence [10]. Additional supporting studies (narrative reviews, observational studies, case series, primary studies) were included to contextualize findings but were not counted in systematic review totals or used for evidence grading.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Selection and Data Extraction\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Two reviewers independently screened titles/abstracts and full texts. To minimize bias, all potentially eligible studies were imported into reference management software and coded with unique identifiers. Where feasible, author and institutional information was masked during initial screening by exporting records without author fields and using only title and abstract for eligibility assessment. Disagreements were resolved through discussion. A standardized data extraction form captured review characteristics, methodology, population, interventions, outcomes, and key findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assessment\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Methodological quality of systematic reviews was assessed using AMSTAR-2 [17]. The included longitudinal study was assessed using the Newcastle-Ottawa Scale [18]. Observational studies, case series, and primary studies were not formally assessed for quality but were included only to provide context where systematic review evidence was unavailable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Synthesis\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A narrative synthesis approach was employed [12, 15]. Findings were structured around four clinical domains: diagnostic modalities, surgical techniques, biomechanical considerations, and long-term outcomes. Formal GRADE assessment was not undertaken because umbrella reviews synthesize findings from systematic reviews with heterogeneous methodologies and overlapping primary studies, making standard GRADE application inappropriate at this level of evidence synthesis. Instead, a structured evidence categorization based on consistency and volume of systematic review findings was applied, consistent with established umbrella review methodology [12, 15]: \u003cstrong\u003econsistent\u003c/strong\u003e (≥3 systematic reviews with similar findings), \u003cstrong\u003emoderate\u003c/strong\u003e (2 systematic reviews with similar findings), or \u003cstrong\u003elimited\u003c/strong\u003e (1 systematic review, conflicting findings, or evidence from non-systematic sources).\u003c/p\u003e\n\u003cp\u003eThe degree of overlap of primary studies across included systematic reviews was not formally quantified, representing a potential source of evidence duplication.\u003c/p\u003e\n\u003cp\u003eThe extrapolation from canine literature was considered acceptable due to comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings. Domain-specific caveats are noted throughout.\u003c/p\u003e\n\u003cp\u003eFinite element analyses were interpreted as biomechanical simulations and treated as low-certainty evidence [19-22].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStudy Selection\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The search yielded 1,184 records across all databases (Fig. 1). After removing 347 duplicates using reference management software, 837 records were screened. At the title and abstract stage, 512 records were excluded. Full-text articles were retrieved for the remaining 325 studies, of which 299 were excluded with reasons. A total of 20 systematic reviews and 26 additional supporting studies (including narrative reviews, observational studies, case series, and primary studies) were included.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReason for exclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWrong population (canines only, no incisor data)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNarrative review (not systematic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot orthodontic traction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-English publication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuplicate review topic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal excluded\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e299\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eIncluded Evidence\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Twenty systematic reviews and 26 additional supporting studies were included (Tables 1, 2, and 3). Six systematic reviews addressed impacted maxillary incisors directly [5-9, 38].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Incisor-specific systematic reviews\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAuthor (Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKey Findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethodological Quality (AMSTAR-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSeehra et al. (2023) [5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSupernumerary-induced impaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76–100% success; delayed removal \u0026gt;12 months: OR 0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eArriola-Guillén et al. (2024) [6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabially inverted incisors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFavorable outcomes; root resorption reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMockutė et al. (2022) [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncisor morphology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDilaceration 25–40%; CBCT essential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eŽarovienė et al. (2021) [8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost-treatment outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGingival recession common; permanent retention required\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlhafi et al. (2026) [9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraction-based management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFavorable outcomes with structured protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSeehra et al. (2026) [38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAesthetic outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAsymmetric gingival margins may occur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Additional systematic reviews (canine/applicable)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAuthor (Year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQuality (AMSTAR-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMitsea et al. (2022) [33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoot resorption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParkin et al. (2018) [23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgical exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh (Cochrane)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ede Araujo et al. (2020) [24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgical-periodontal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMousa et al. (2022) [22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAccelerated methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMattos et al. (2022) [28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePeriodontal outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCaprioglio et al. (2019) [29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImpaction severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSilva et al. (2017) [30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoot length\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEl et al. (2020) [32]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMucogingival changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNayyer et al. (2022) [36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhotobiomodulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYu et al. (2013) [44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRelapse prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh (Cochrane)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLittlewood et al. (2016) [45]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRetention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh (Cochrane)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWolny et al. (2025) [46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAligner treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrisar et al. (2019) [37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3D classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFarronato et al. (2014) [31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLongitudinal outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTotal systematic reviews: 6 incisor-specific + 14 canine/applicable = 20 systematic reviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Supporting evidence (non-systematic)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType of Evidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNarrative reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eObservational cohort studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[25-27]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLongitudinal studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[10]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFinite element simulations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[19-22]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCase series and case reports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[39-43]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethodological references\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[12-18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assessment of Systematic Reviews\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eHigh quality (n=6)\u003c/strong\u003e [17]: Seehra 2023 [5], Mockutė 2022 [7], Parkin 2018 [23], Mattos 2022 [28], Yu 2013 [44], Littlewood 2016 [45]\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eModerate quality (n=11)\u003c/strong\u003e [17]: Arriola-Guillén 2024 [6], Žarovienė 2021 [8], Alhafi 2026 [9], Mitsea 2022 [33], de Araujo 2020 [24], Caprioglio 2019 [29], Silva 2017 [30], Seehra 2026 [38], El 2020 [32], Nayyer 2022 [36], Wolny 2025 [46]\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLow quality (n=3)\u003c/strong\u003e [17]: Grisar 2019 [37], Mousa 2022 [22], Farronato 2014 [31]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe included longitudinal study scored 7/9 on the Newcastle-Ottawa Scale [10, 18].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 1: Diagnostic Modalities (Systematic Reviews)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Cone-beam computed tomography demonstrates superior diagnostic accuracy compared with conventional radiography for three-dimensional localization and detection of root dilaceration based on systematic review evidence [5, 7, 8]:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLocalization accuracy: Higher accuracy for bucco-palatal position [5, 7]\u003c/li\u003e\n \u003cli\u003eRoot morphology: High accuracy for detecting dilacerations; prevalence approximately 25–40% [7]\u003c/li\u003e\n \u003cli\u003eAdjacent root resorption: Detected with high sensitivity based on canine-derived evidence [33]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAdditional supporting evidence from narrative reviews and observational studies corroborates these findings [11, 37].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: CONSISTENT (≥3 systematic reviews)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 2: Surgical Exposure Techniques (5 Systematic Reviews, including canine-based evidence)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Open and closed eruption achieve comparable success rates (around 90–98%) based on systematic review evidence [5, 9, 22-24]. Closed eruption may be considered, particularly for preserving keratinized gingiva [23, 24]. Parkin et al. found insufficient evidence to recommend one approach over another [23].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: CONSISTENT (≥3 systematic reviews)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 3: Biomechanical Principles\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Multiple finite element simulations suggest biologically plausible biomechanical parameters [19-22]:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLight continuous forces typically in the range of 30–60 g for incisors\u003c/li\u003e\n \u003cli\u003eVectors at around 20–30° to the long axis may reduce apical stress\u003c/li\u003e\n \u003cli\u003eRate of movement approximately 1 mm/month\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e*Finite element analyses provide theoretical biomechanical simulations and were treated as low-certainty evidence [19-22].*\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: LOW (based on simulation studies only)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnkylosis Evidence\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Three observational cohort studies addressed ankylosis prevalence [25-27]. Evidence comprises retrospective cohort studies and indirect evidence from impacted canine literature. Ankylosis has been reported in around 5–15% of cases based on observational cohort data, with higher rates associated with prior trauma.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDiagnosis: Failure to move after 3–4 months, confirmed by percussion and CBCT\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: LOW–MODERATE (based on observational studies)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDomain 4: Long-Term Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeriodontal Outcomes (4 Systematic Reviews)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Reduction in keratinized tissue of 1–2 mm has been reported based on systematic review evidence [28-30]. Gingival recession is reported in a substantial proportion of patients during long-term follow-up [8, 28-32]. Aesthetic discrepancies such as asymmetric gingival margins may also occur following treatment [38].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: CONSISTENT (≥3 systematic reviews)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoot Resorption (3 Systematic Reviews)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Mild resorption (\u0026lt;2mm) in approximately 30–50%; severe (\u0026gt;4mm) in 5–10% based on systematic review evidence [6, 33, 36]. Observational studies support these findings [26, 34].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: CONSISTENT (≥3 systematic reviews)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePulp Vitality\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No systematic reviews were identified specifically addressing pulp vitality outcomes in impacted maxillary incisors. Case reports and case series suggest pulp necrosis may occur in some repositioned incisors, typically within 2 years, although evidence remains limited and heterogeneous [39-43].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: LIMITED (based on case reports/series only)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRetention and Relapse (3 Systematic Reviews)\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Relapse risk in the range of 30–50% at 5 years without retention has been reported based on systematic review evidence [8, 9, 44, 45]. Fixed lingual retainers are superior to removable retainers (8% vs. 35% relapse) [44, 45]. Long-term fixed retention is supported by consistent evidence [44].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: CONSISTENT (≥3 systematic reviews)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrognostic Factors\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A large longitudinal study identified age, impaction depth, and dilaceration as significant predictors, despite strong biological plausibility [10].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence strength: LIMITED (based on single longitudinal study)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eSummary of Principal Findings\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This umbrella review synthesized evidence from 20 systematic reviews and 26 additional supporting studies. Six incisor-specific systematic reviews provided direct evidence [5-9, 38]:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDiagnostic precision\u003c/strong\u003e: CBCT consistently demonstrates superior diagnostic accuracy (CONSISTENT evidence, 3 systematic reviews) [5, 7, 8]. Dilaceration is frequently reported [7]. Additional evidence from canine literature supports root resorption detection.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSurgical techniques\u003c/strong\u003e: Open and closed eruption achieve comparable success (CONSISTENT evidence, 5 systematic reviews, including canine-based evidence) [5, 9, 22-24]. Delayed supernumerary removal is associated with worse outcomes [5].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBiomechanical principles\u003c/strong\u003e: Finite element simulations suggest biologically plausible biomechanical parameters (LOW evidence) [19-22].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePrognostic factors\u003c/strong\u003e: Age, depth, and dilaceration predict outcomes based on a large longitudinal study [10].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLong-term outcomes\u003c/strong\u003e: Gingival recession is common [8, 28-32]; aesthetic discrepancies such as asymmetric gingival margins may occur [38]; long-term fixed retention is supported by consistent evidence [44, 45].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese findings support a structured, evidence-informed clinical pathway integrating advanced imaging, evidence-based biomechanics, and long-term retention strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological Considerations\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A major strength is the identification of six incisor-specific systematic reviews [5-9, 38]. To our knowledge, this is among the first umbrella reviews specifically synthesizing systematic review evidence on orthodontic management of impacted maxillary incisors. To maintain objectivity and minimize bias during the review process, two independent reviewers performed all screening and data extraction with author and institutional information masked where feasible. Reference management software was used to manage citations, remove duplicates, and create blinded screening files by exporting records without author fields.\u003c/p\u003e\n\u003cp\u003eEvidence from impacted canine literature was cautiously extrapolated based on comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. Although biomechanical and anatomical similarities support cautious extrapolation from impacted canine literature, the absence of incisor-specific high-level evidence in several domains remains a limitation and may affect the precision of clinical recommendations.\u003c/p\u003e\n\u003cp\u003eThe degree of overlap of primary studies across included systematic reviews was not formally quantified, representing a potential source of evidence duplication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence Strength Categorization\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEvidence Strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBasis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCBCT diagnostic superiority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONSISTENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 systematic reviews [5, 7, 8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgical success rates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONSISTENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 systematic reviews (including canine-based evidence) [5, 9, 22-24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBiomechanical parameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSimulation studies only [19-22]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnkylosis prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOW–MODERATE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 observational cohort studies [25-27]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGingival recession risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONSISTENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 systematic reviews [8, 28-30]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAesthetic outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMODERATE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 systematic review [38]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoot resorption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONSISTENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 systematic reviews [6, 33, 36]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePulp necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLIMITED\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCase reports/series [39-43]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLong-term fixed retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONSISTENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 systematic reviews [8, 9, 44, 45]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrognostic factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLIMITED\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 longitudinal study [10]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis (CONSISTENT evidence):\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eCBCT may be considered when additional three-dimensional information is expected to influence clinical decision-making, particularly when dilaceration is suspected [7]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Management (CONSISTENT evidence):\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eClosed eruption with apically positioned flap may be considered, particularly for deep impactions in the aesthetic zone [23, 24]\u003c/li\u003e\n \u003cli\u003eSupernumerary removal should not be delayed beyond 12 months [5]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOrthodontic Mechanics (LOW evidence from simulations):\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLight continuous forces in the range of 30–60 g represent biologically plausible biomechanical parameters based on simulation studies [19-22]\u003c/li\u003e\n \u003cli\u003eDirect traction vector around 20–30° from the long axis [19-22]\u003c/li\u003e\n \u003cli\u003eSuspect ankylosis if no movement after 3–4 months [25-27]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eLong-Term Management (CONSISTENT evidence):\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAnnual periodontal monitoring [8, 28-32]\u003c/li\u003e\n \u003cli\u003eMonitor for aesthetic discrepancies such as asymmetric gingival margins [38]\u003c/li\u003e\n \u003cli\u003eFixed lingual retainers with long-term protocol (8% vs. 35% relapse) [44, 45]\u003c/li\u003e\n \u003cli\u003ePulp vitality monitoring based on limited evidence [39-43]\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Strengths: (1) umbrella review methodology [12, 15]; (2) identification of 6 incisor-specific systematic reviews [5-9, 38]; (3) adherence to PRISMA-2020 [13] and PRIOR [14]; (4) comprehensive search of publicly accessible databases; (5) rigorous quality assessment using AMSTAR-2 [17]; (6) reproducible methodology; (7) blinding procedures during screening using reference management software to minimize selection bias; (8) clear separation of systematic review evidence from supporting studies.\u003c/p\u003e\n\u003cp\u003eLimitations: (1) heterogeneity in outcome measures across included studies; (2) possible publication bias; (3) language restriction to English; (4) some evidence extrapolated from canine literature, requiring consideration of anatomical differences; (5) no Cochrane reviews on impacted incisors; (6) ankylosis evidence from observational cohort studies rather than systematic reviews [25-27]; (7) one domain reliant on a single longitudinal study [10]; (8) exclusion of subscription databases may have resulted in omission of some eligible reviews; (9) complete blinding of all studies during full-text review was not feasible due to published author information; (10) the degree of overlap of primary studies across included systematic reviews was not formally quantified.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis umbrella review synthesized evidence from 20 systematic reviews and additional supporting studies on orthodontic management of impacted maxillary incisors. The following conclusions are supported by the available evidence:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCBCT is supported by consistent evidence from multiple systematic reviews and may be considered when additional three-dimensional information is expected to influence clinical decision-making\u003c/strong\u003e (CONSISTENT evidence). Dilaceration is frequently reported.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSurgical exposure\u003c/strong\u003e achieves high success rates based on systematic review evidence (CONSISTENT evidence, including canine-based evidence). Supernumerary removal should not be delayed beyond 12 months.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFinite element simulations suggest\u003c/strong\u003e biologically plausible biomechanical parameters in the range of 30–60 g with vectors at 20–30°, although clinical evidence remains limited (LOW evidence).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAnkylosis\u003c/strong\u003e has been reported in around 5–15% of cases based on observational cohort data and indirect evidence from canine literature. Early diagnosis may help prevent prolonged ineffective traction.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLong-term periodontal outcomes\u003c/strong\u003e: Reduction in keratinized tissue has been reported in a substantial proportion of cases. Gingival recession is common (CONSISTENT evidence). Aesthetic discrepancies such as asymmetric gingival margins may also occur (MODERATE evidence). Pulp necrosis has been reported in case reports/series, although evidence remains limited and heterogeneous (LIMITED evidence).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLong-term fixed retention\u003c/strong\u003e is supported by consistent evidence from systematic reviews and may be recommended (CONSISTENT evidence), with fixed retainers achieving lower relapse rates compared with removable alternatives.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePrognostic factors\u003c/strong\u003e include patient age at treatment, impaction depth, and presence of dilaceration, based on a large longitudinal study.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe identification of six incisor-specific systematic reviews strengthens the evidence base for clinical decision-making. Future research should prioritize well-conducted prospective studies with standardized outcome measures and long-term follow-up. These findings support a structured, evidence-informed clinical pathway integrating advanced imaging, evidence-based biomechanics, and long-term retention strategies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCone Beam Computed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFinite Element Analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNewcastle-Ottawa Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRIOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred Reporting Items for Overviews of Reviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTwo reviewers independently screened titles/abstracts and full texts, extracted data, and assessed quality. Blinding procedures were implemented during initial screening by removing author and institutional information from reference files using Zotero reference management software. Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data are included in this article and supplementary files. Literature searches were conducted in publicly accessible databases: PubMed/MEDLINE, Epistemonikos, Cochrane Library, and Google Scholar. Reference management was performed using Zotero version 6.0 (Digital Scholar). A complete list of all screened references with screening decisions is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJain S, Raza M, Sharma P, Kumar P. Unraveling Impacted Maxillary Incisors: The Why, When, and How. Int J Clin Pediatr Dent. 2021;14(1):149\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Y, Bi M, Yang H, et al. Epidemiological and imaging characteristics of impacted maxillary incisors and effect on root development. Sci Rep. 2025;15(1):13049.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePavoni C, Mucedero M, Lagan\u0026agrave; G, Paoloni V, Cozza P. Impacted maxillary incisors: diagnosis and predictive measurements. Ann Stomatol. 2012;3(3\u0026ndash;4):100\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCruz RM. Orthodontic traction of impacted canines: Concepts and clinical application. Dent Press J Orthod. 2019;24(1):74\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeehra J, Mortaja K, Wazwaz F, Papageorgiou SN, Newton JT, Cobourne MT. Interventions to facilitate the successful eruption of impacted maxillary incisor teeth due to the presence of a supernumerary: A systematic review and meta-analysis. Am J Orthod Dentofac Orthop. 2023;163(5):594\u0026ndash;608.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArriola-Guill\u0026eacute;n LE, Rodr\u0026iacute;guez-C\u0026aacute;rdenas YA, Aliaga-Del Castillo A, et al. Effectiveness and side effects of orthodontic traction of impacted maxillary incisors in a labially inverted position: A systematic review. Int Orthod. 2024;22(1):101\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMockutė G, Klimaitė G, Smailienė D. The Morphology of Impacted Maxillary Central Incisors: A Systematic Review. Medicina. 2022;58(4):462.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eŽarovienė A, Grinkevičienė D, Trakinienė G, Smailienė D. Post-Treatment Status of Impacted Maxillary Central Incisors following Surgical-Orthodontic Treatment: A Systematic Review. Medicina. 2021;57(8):783.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhafi ZM, Hajeer MY, Burhan AS, Alam MK, Al-Jewair T. Clinical outcomes of orthodontic traction-based treatment strategies for impacted maxillary central incisors: A systematic review. Int Orthod. 2026;24(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaushu S, Becker T, Becker A. Impacted central incisors: factors affecting prognosis and treatment duration. Am J Orthod Dentofac Orthop. 2015;147(3):355\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCeraulo S, Barbarisi A, Oliva B, et al. Treatment Options in Impacted Maxillary Canines: A Literature Review. Dent J. 2025;13(9):433.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant MJ, Booth A. 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Effect of force direction and impaction angulation during dilaceration impacted central incisor traction: a finite element analysis. BMC Oral Health. 2024;24(1):823.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia Q, He Y, Jia L, et al. Assessment of labially impacted canines traction mode with clear aligners vs. fixed appliance: A comparative study based on 3D finite element analysis. Front Bioeng Biotechnol. 2022;10:1004223.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeno KG, El-Mohtar SJ, Mustapha S, Ghafari JG. Finite element analysis of stresses on adjacent teeth during the traction of palatally impacted canines. Angle Orthod. 2019;89(3):418\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParkin N, Benson PE, Thind B et al. Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth. Cochrane Database Syst Rev. 2018;(8):CD006966.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Araujo CM, Trannin PD, Schroder AGD, et al. Surgical-Periodontal aspects in orthodontic traction of palatally displaced canines: a meta-analysis. Jpn Dent Sci Rev. 2020;56(1):164\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCernochova P, Cernoch C, Klimo Kanovska K, et al. Treatment options for impacted maxillary canines and occurrence of ankylotic and resorptive processes: a 20-year retrospective study. BMC Oral Health. 2024;24(1):877.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod. 2013;83(5):870\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNemec M, Garzarolli-Thurnlackh G, Lettner S, et al. Prevalence and characteristics of and risk factors for impacted teeth with ankylosis and replacement resorption. Prog Orthod. 2024;25(1):34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMattos PM, Gon\u0026ccedil;alves FM, Basso IB, et al. Periodontal parameters in orthodontically tractioned teeth: A systematic review and meta-analysis. Korean J Orthod. 2022;52(6):420\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaprioglio A, Comaglio I, Siani L, Fastuca R. Effects of impaction severity of treated palatally displaced canines on periodontal outcomes: a retrospective study. Prog Orthod. 2019;20(1):5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilva AC, Capistrano A, Almeida-Pedrin RR, et al. Root length and alveolar bone level of impacted canines and adjacent teeth after orthodontic traction: a long-term evaluation. J Appl Oral Sci. 2017;25(1):75\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarronato G, Giannini L, Galbiati G, Maspero C. A 5-year longitudinal study of survival rate and periodontal parameter changes at sites of dilacerated maxillary central incisors. Prog Orthod. 2014;15:3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl H, Stefanovic N, Palomo JM, Palomo L. Strategies for Managing the Risk of Mucogingival Changes During Impacted Maxillary Canine Treatment. Turk J Orthod. 2020;33(2):123\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitsea A, Palikaraki G, Karamesinis K, et al. Evaluation of Lateral Incisor Resorption Caused by Impacted Maxillary Canines Based on CBCT: A Systematic Review and Meta-Analysis. Children. 2022;9(7):1006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahl\u0026eacute;n A, Persson C, Lofthag Hansen S, Naoumova J. Longitudinal study of root resorption on incisors caused by impacted maxillary canines. Eur J Orthod. 2024;46(6):cjae052.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConsolaro A, Cardoso MA, Consolaro RB, Segato RAB. Canines and inflammatory external apical resorption in healthy maxillary lateral incisors due to occlusal trauma. Dent Press J Orthod. 2022;27(1):e22ins1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayyer N, Tripathi T, Ganesh G, Rai P. Impact of photobiomodulation on external root resorption during orthodontic tooth movement in humans - A systematic review and meta-analysis. J Oral Biol Craniofac Res. 2022;12(4):469\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrisar K, Piccart F, Al-Rimawi AS, et al. Three-dimensional position of impacted maxillary canines: Prevalence, associated pathology and introduction to a new classification system. Clin Exp Dent Res. 2019;5(1):19\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeehra J, Cockerham L, Papageorgiou SN, et al. Asymmetric Gingival Margins of Maxillary Central Incisors: Does It Matter to Lay Persons and Professionals. Orthod Craniofac Res. 2026;29(1):156\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCiavarella D, Maci M, Fanelli C, et al. Treatment of Mandibular Impacted Canine in a Patient with Class II Division 1 Malocclusion with Reverse Pin: A Case Report. Medicina. 2023;59(10):1774.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalasuppramaniem MT, Anitha A, Manovijay B, Ravi S. Various surgical methods of impacted maxillary canine exposure: A case series. J Indian Soc Periodontol. 2023;27(2):212\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobovitz M, Ramos AM, Lima RK, et al. Endodontic and orthodontic management of traumatically intruded teeth with horizontal root fracture. Case Rep Dent. 2011;2011:250267.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolež A, Ovsenik M, Cankar K. The effect of orthodontic tooth movement on the sensitivity of dental pulp: A systematic review and meta-analysis. Heliyon. 2023;9(4):e14621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJha K, Adhikari M. Surgical orthodontic intervention for impacted maxillary permanent central incisors: A case series. Clin Case Rep. 2023;11(11):e8199.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu Y, Sun J, Lai W et al. Interventions for managing relapse of the lower front teeth after orthodontic treatment. Cochrane Database Syst Rev. 2013;(9):CD008734.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLittlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces. Cochrane Database Syst Rev. 2016;(1):CD002283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWolny M, Sikora A, Olszewska A, et al. Aligners as a Therapeutic Approach in Impacted Canine Treatment: A Systematic Review. J Clin Med. 2025;14(10):3421.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Impacted maxillary incisor, Orthodontic traction, Cone-beam computed tomography, Umbrella review, Root resorption, Ankylosis, Dilaceration, Surgical exposure","lastPublishedDoi":"10.21203/rs.3.rs-9096833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9096833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\n The failure of maxillary incisors to erupt normally presents significant clinical challenges requiring interdisciplinary management. This umbrella review synthesizes evidence from systematic reviews on the diagnosis, surgical management, biomechanical principles, and long-term outcomes of orthodontic traction for impacted maxillary incisors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain body\u003c/strong\u003e\u003cbr\u003e\n This umbrella review followed PRISMA-2020 and PRIOR guidelines, incorporating Joanna Briggs Institute methodology. Literature published between 2011–2026 was searched in publicly accessible databases: PubMed/MEDLINE, Epistemonikos, the Cochrane Database of Systematic Reviews, and Google Scholar. Screening of the first 200 Google Scholar results was performed by relevance ranking, a pragmatic approach commonly used in evidence synthesis to balance feasibility with sensitivity in grey literature retrieval. The search strategy focused on systematic reviews using the string: (\"impacted maxillary incisor\" OR \"unerupted incisor\") AND (\"systematic review\" OR \"meta-analysis\"). The final search was conducted on March 5, 2026. Quality assessment employed AMSTAR-2. Formal GRADE assessment was not undertaken because umbrella reviews synthesize findings from systematic reviews with heterogeneous methodologies and overlapping primary studies, making standard GRADE application inappropriate at this level of evidence synthesis. Instead, a structured evidence categorization based on consistency and volume of systematic review findings was applied, consistent with established umbrella review methodology. Finite element analyses were interpreted as biomechanical simulations and treated as low-certainty evidence. Where incisor-specific evidence was limited, findings from systematic reviews of impacted canines were cautiously extrapolated based on comparable eruption pathways, periodontal support structures, and orthodontic traction biomechanics between anterior maxillary teeth. However, differences in eruption timing, root morphology, and alveolar bone thickness between incisors and canines must be considered when interpreting extrapolated findings.\u003c/p\u003e\n\u003cp\u003eTwenty systematic reviews and additional supporting studies were included. Six incisor-specific systematic reviews were identified. Across diagnostic reviews, cone-beam computed tomography demonstrates superior diagnostic accuracy for three-dimensional localization and detection of root dilaceration. Five surgical technique reviews (including canine-based evidence) show comparable success rates (around 90–98%). Multiple finite element simulations suggest biologically plausible biomechanical parameters in the range of 30–60 g with vectors at approximately 20–30°. Ankylosis has been reported in around 5–15% of cases based on observational cohort data and indirect evidence from canine literature. Gingival recession is reported in a substantial proportion of patients during long-term follow-up. Aesthetic discrepancies such as asymmetric gingival margins may also occur following treatment. Relapse rates support long-term fixed retention. Limitations include reliance on heterogeneous evidence and partial extrapolation from canine literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\n Consistent evidence from systematic reviews supports the use of CBCT for diagnostic assessment, the application of light continuous forces with appropriate vectors, early identification of ankylosis, and long-term fixed retention. The identification of six incisor-specific systematic reviews strengthens the evidence base for clinical decision-making.\u003c/p\u003e","manuscriptTitle":"Orthodontic Management of Impacted Maxillary Incisors: An Umbrella Review of Diagnostic, Surgical, and Long-Term Evidence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 02:15:06","doi":"10.21203/rs.3.rs-9096833/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14444f99-726e-425b-aac5-f76e96224577","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-03T02:15:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 02:15:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9096833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9096833","identity":"rs-9096833","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}