Orthodontic Treatment of Impacted Teeth. Adrian Becker

seven identical questionnaires and was instructed to complete one of the questionnaires on each post‐treatment day, for each of the following seven days. Information was then collected from the answers regarding pain, oral function, general disability, limitation in eating, absence from school and related parameters. The results for the group of patients who had had open exposure were then analysed and compared with those for the patients who had undergone closed exposure.

      In general, it was found that full recovery from an open eruption exposure required five days, whereas only three days were required for a closed procedure. It was particularly observed that, in the case of the longer recovery period (the open technique), there was a higher level of pain, greater difficulty in eating and swallowing and an increased need for analgesics. More specifically, it was found that there was much greater discomfort with the open exposure in the case of a palatally impacted canine, especially if bone removal had been performed. However, it is noteworthy that exposure of impacted teeth with a buccal approach resulted in a high level of discomfort, regardless of the surgical method that had been employed. It may be speculated that this was due to the fact that paranasal and oral musculature is severed during buccal procedures and the surgical flap is sited in highly mobile oral mucosa.

Table 5.1 summarizes the effects on QoL issues immediately post treatment. We can see the advantages and disadvantages of complete flap closure (healing by primary intention) compared with the alternative open exposure techniques, in which the opening in the tissue over the impacted tooth is maintained by reducing the size of the flap and packing the wound or by repositioning the flap more apically (healing by secondary intention).

Cooperation between surgeon and orthodontist

      From the discussion in this chapter so far, it will have become quite clear that there are severe limitations in the ability of the surgeon to single‐handedly treat the cases discussed. We have sought to demonstrate that, in most situations, the inclusion of orthodontic procedures offers a better chance of success. Indeed, today orthodontists are playing an increasingly important role in the initial stages of the treatment of impacted teeth, in particular by providing the traction that is necessary to encourage eruption. In many of the cases where teeth were previously felt to have poor prospects for eruption, the contribution of the orthodontist to the ultimate successful result has been the ‘game changer’.

Once the oral surgeon has made the impacted tooth accessible, its destiny is largely dependent on the ability and the ingenuity of the orthodontist, to apply light traction in an appropriate direction, efficiently and with the appropriate means. If orthodontic treatment is available to the patient, the other highly empirical and suspect procedures listed at the beginning of this chapter, which may otherwise be suggested by the surgeon, become superfluous. There is no evidence that suggests that these procedures may improve the opportunity for orthodontic resolution, without thereby causing consequential harm.

Fig. 5.11 A case of bilateral palatal impaction of maxillary canine treatment with the closed eruption surgical technique. (a) Anterior section of the pre‐treatment panoramic view to show canines almost contacting in the midline. (b) Panoramic view of the post‐treatment result. (c) The treated result seen 14 years post treatment with relapsed incisor overjet and overbite. (d) Close‐up intra‐oral view of the teeth from the labial side, showing the canines to be indistinguishable from their neighbouring teeth in terms of their crown length, gingival contour and excellent appearance. (e) Clinical view of the palatal sides of the two canines, 14 years post treatment, to show normal gingival contour, normal crown length and no recession. No reparative periodontal procedures were performed after the original closed surgical exposure. (f) Periapical radiographs of the teeth showing excellent bone support and pattern.

Fig. 5.12 (a) Mild palatal displacement of the right maxillary canine located very high in the line of the arch (Group 3 canine) and treated with full‐flap closure on the buccal side (closed eruption technique). (b, c) The right and left sides are indistinguishable at the completion of treatment.

      It may therefore be concluded that, with respect to the treatment of impacted teeth, the aims of the oral surgeon should be limited to:

       Provision of access to the buried tooth.

       Elimination of any obstruction from the tooth’s eruptive path, such as supernumerary teeth, odontomes or thickened overlying mucosa.

       Maintaining haemostasis, thereby enabling active participation of the orthodontist at surgery in bonding an attachment to the exposed teeth, which is so critical in ensuring success.

      In summary, it is our contention that the single most important aim of surgical involvement is to provide access to a tooth that is otherwise buried. This will enable the orthodontist to provide the means, in as simple a manner as possible, by which force may be applied to the tooth in question, through several subsequent visits over a longish time‐span. For this to happen, an attachment has to be securely bonded and a firm ligature, or other form of intermediary, drawn to the exterior, to which steel wires, super‐elastic nickel–titanium wires, elastic ligatures or an auxiliary spring may be tied. The responsibility for the successful execution of this procedure is shared between the oral surgeon and the orthodontist, each complementing the other in applying their very special and different skills to the resolution of the immediate task. Together they possess all the tools that are needed to complete the job, which neither is equipped to do alone.

If bonding an attachment to the tooth is to be carried out a few weeks after the surgery has been performed, then the presence of the orthodontist at the surgeon’s side will be superfluous. However, the reliability of the bonding at this later date will be much poorer [3]. The surgeon will need to expose the tooth much more widely, place surgical packs and aim for healing ‘by secondary intention’. This has been pointed out above and will be explained in greater detail in later chapters.

Table 5.1 Immediate effects of closed and open exposure treatments on quality of life.

Primary full‐flap closure (closed exposure)
Advantages
Rapid healing
Less discomfort
Good post‐operative haemostasis
Less impediment to function
Conservative bone removal
Immediate traction possible
High degree of reliability of bonding possible in close proximity to resorbing root area
Disadvantages
Presence of orthodontist needed
Bond failure dictates re‐exposure
Open exposure
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