Orthodontic Treatment of Impacted Teeth. Adrian Becker

that the treatment of impacted teeth has caught the imagination of many in the dental profession. The challenge has, over the years, been taken up by the general practitioner and by a number of dental specialists, including the paedodontist, the periodontist, the orthodontist and, most of all, the oral and maxillofacial surgeon. Each of these professionals has much ‘input’ to offer in the resolution of the immediate problem and each is able to show some fine results. However, no single individual on this specialist list can completely and successfully treat more than a few of these cases without the assistance of one or more of others of his/her colleagues on that list. Thus, the type of treatment prescribed may depend upon which of these dental specialists sees the patient first and the level of his/her experience with the problem in his/her field. Such treatment may involve surgical exposure and packing, orthodontic space opening, perhaps autotransplantation, or a surgical dento‐alveolar set‐down procedure, or even just an abnormally angulated prosthetic crown reconstruction.

      Experience has come to show that the orthodontic/surgical modality has the potential to achieve the most satisfactory results in the long term. Despite this, many orthodontists have ignored or abrogated their responsibility towards the subject of impacted teeth to others, accounting for the popularity of other modalities of treatment. The subject has become something of a Cinderella of dentistry.

      Within the orthodontic/surgical modality, much room exists for debate as to what should be done first and to what lengths each of the two specialties represented should go in the zealous pursuit of its allotted portion of the procedure. The literature offers scant information and guidance to resolve these issues, leaving the practitioner to fend for him/herself, with a problem that has ramifications in several different specialist realms.

      This book discusses the many aspects of impacted teeth, including their prevalence, aetiology, diagnosis, treatment timing, treatment and prognosis. Since these aspects differ between incisors and canines, and between these and the other teeth, a separate chapter is devoted to each. The material presented is based on the findings of clinical research that has been carried out in Jerusalem by a small group of clinicians over the past 15 years or so, at the Hebrew University – Hadassah School of Dental Medicine, founded by the Alpha Omega Fraternity and from the gleanings of clinical experience in the treatment of many hundreds of my patients, young and old.

      An overall and recommended approach to the treatment of impacted teeth is presented and emphasis is placed on the periodontal prognosis of the results. Among the many other aspects of this book, the intention has been to propose ideas and principles that may be used to resolve even the most difficult impaction, employing orthodontic auxiliaries of many different types and designs. None of these is specific to any particular orthodontic appliance system or treatment ‘philosophy’, notwithstanding the author’s own personal preferences, which will become obvious from many of the illustrations. These auxiliaries may be used with equal facility in virtually any appliance system with which the reader may be fluent. The only limitation in the use of these ideas and principles are those imposed on the reader by his/her own imagination and willingness to adapt.

      The orthodontic manufacturers’ catalogues are replete with the more commonly and routinely used attachments, archwires and auxiliaries, which are offered to the profession with the aim of streamlining the busy practice. These items have not been tailored to the demands of the clinical issues that are raised in this book. These issues, by their very nature, are exceptional, problematic and often unique, while occurring alongside and in addition to the routine. Among the more common limitations self‐imposed by many orthodontists has been the disturbing trend to rely so completely upon the use of preformed and pre‐welded attachments that they have forgotten the arts of welding and soldering and no longer carry the necessary modest equipment. This then restricts one’s practice to using only what is available and sufficiently commonly used to make it commercially worthwhile for the manufacturer to produce. By consenting to this unhealthy situation, the orthodontist is agreeing to work with ‘one hand tied behind his/her back’ and treatment results with inevitably suffer.

      I acknowledge and am grateful for the help given me by several colleagues in the preparation of this book. An excellent professional relationship has been established, and has withstood the test of time, with two senior members of the Department of Oral and Maxillofacial Surgery at Hadassah, with whom a modus operandi has been developed, in the treatment of our patients. Professor Arye Shteyer, Head of the Department, and, subsequently, Professor Joshua Lustmann have educated me in the finer points of surgical procedure and care while, at the same time, have demonstrated a respect and understanding of the needs of the orthodontist at the time of surgery. I am grateful to them for their collaboration in the writing of Chapter 3.

Dr Ilana Brin read the original manuscript and made some useful suggestions, which have been included in the text. I am grateful to Dr Alexander Vardimon for his comments regarding the use of magnets and to Dr Tom Weinberger for the discussions that we have had regarding several issues realised in the book. My wife, Sheila, read the earlier drafts and made many important recommendations and corrections. More than anyone else, she encouraged me to keep writing during the many months when other and more pressing responsibilities could have been used as justifiable excuses for putting the project aside.

      My colleagues Dr Monica Barzel, Dr Yocheved ben Bassat, Dr Gabi Engel, Dr Doron Harary, Dr Tom Weinberger and Professor Yerucham Zilberman, and my former graduate students Dr Yossi Abed, Dr Dror Eisenbud, Dr Sylvia Geron, Dr Immanuel Gillis, Dr Raffi Romano and Dr Nir Shpack, have provided me with several of the illustrations included here and I am indebted to them.

      I am grateful, too, to Ms Alison Campbell, Commissioning Editor at Martin Dunitz Publishers and to Dr Joanna Battagel, Technical Editor, for their constructive and professional critique of the manuscript, which contributed so much to its ultimate format. I also thank Naomi and Dudley Rogg, of the British Hernia Centre, for the computer and office facilities that they placed at my disposal during my short sabbatical in London in the latter stages of the preparation of the work for publication.

      Permission to use illustrations from my own articles that were published in various learned journals was granted by the publishers of those journals or by the owners of the copyright, as follows:

      Figure 5.13 was reprinted from Pertz B, Becker A, Chosak A, The repositioning of a traumatically‐intruded mature rooted permanent incisor with a removable appliance. J. Pedodont 1982; 6: 343–354, with kind permission of the Journal of Pedodontics Inc.

      Figure 5.4 and 5.12 were reprinted from Becker A, Stern N, Zelcer Z, Utilization of a dilacerated incisor tooth as its own space maintainer. J Dent 1976; 4: 263–264, with kind permission from Elsevier Science Ltd, The Boulevard, Langford Lane, Kidlington OX5 1GB, UK.

      Figures 9.8–9.14 were reprinted from Becker A, Shteyer, A, Bimstein, E, Lustmann, J, Cleidocranial dysplasia: part 2 – a Treatment Protocol for the Orthodontic and Surgical Modality, Am J Orthod Dentofac Orthop 1997; 111: 173–183, with kind permission of Mosby‐Year Book Inc., St Louis, MO, USA.

      Figure 6.35 was reprinted from Kornhauser, S, Abed, Y, Harary, D, Becker, A, The resolution of palatally‐impacted canines using palatalocclusal force from a buccal auxiliary, Am J Orthod Dentofac Orthop 1996; 110: 528–534, with kind permission of Mosby‐Year Book Inc., St Louis, MO, USA.

      I am very thankful for their cooperation and for their agreement.

      Adrian Becker

      Jerusalem

      Preface to the Second Edition

      In the nine years that have elapsed since the publication of the first edition of this book, much has changed in the field of orthodontics in general and, perhaps even more so, as it relates to the treatment of impacted teeth. The advances in imaging, particularly cone beam computerized