Clinical Outcomes of Surgical–Orthodontic Management of Impacted Mandibular Canines: A Systematic Review

Background: Impaction of mandibular canines is an uncommon clinical condition, and transmigration represents a severe positional variant within this spectrum. In contrast to maxillary canine impaction, the management of impacted mandibular canines remains less standardized and largely experience-based. This systematic review aimed to critically evaluate the clinical outcomes of surgical exposure followed by orthodontic traction in impacted mandibular canines. Methods: A systematic search was conducted across five electronic databases (PubMed, Web of Science, Scopus, Embase, and Cochrane Library) up to February 2026. A total of 1512 records were identified; after duplicate removal, 1307 studies underwent title and abstract screening. Fifteen full-text articles were assessed for eligibility, and four retrospective analytical studies met the predefined inclusion criteria. The primary outcome was successful orthodontic alignment. Secondary outcomes included treatment duration and reported complications. Risk of bias was assessed using ROBINS-I, and certainty of evidence was evaluated according to the GRADE approach. Results: Success rates ranged from 57% to 100% across studies. Overall, 31/42 canines (73.8%) were reported as successfully aligned; however, heterogeneity in case selection, outcome definitions, and reporting precluded quantitative synthesis. In most studies, success was defined primarily as positional alignment within the dental arch, with limited or absent assessment of periodontal status, pulp vitality, functional integration, or long-term stability. All included studies were judged to have a serious overall risk of bias. According to GRADE, the certainty of evidence for all evaluated outcomes was very low. Conclusions: Surgical exposure followed by orthodontic traction may represent a feasible option in carefully selected cases of impacted mandibular canines, particularly in younger patients and in the absence of severe displacement. However, given the serious risk of bias, small cumulative sample size, and very low certainty of evidence, these estimates must be interpreted with extreme caution. Unlike maxillary canine impaction, the current evidence base does not support protocol-driven management for mandibular cases, and clinical decision-making remains primarily individualized.