Orthodontic Minor surgery

Surgical procedures carried out as an adjunct to or in

conjunction with orthodontic treatment are termed as

surgical orthodontics.

These surgical procedures are usually carried out to eliminate

an etiologic factor or to correct severe dentofacial

abnormalities that cannot be satisfactorily treated by growth

modification procedures or orthodontic camouflage.

Retained deciduous teeth misplaced tooththe eruption of permanent central incisor.

Surgical orthodontic procedures are broadly classified as

a) minor surgical procedures

b) major surgical procedures .

Most minor surgical procedures are an integral part of

orthodontic therapy

The major procedures are aimed at treatment of severe

skeletal malocclusion or dentofacial deformities that cannot

be satisfactorily treated by orthodontic treatment alone.

There should be good co-ordination between oral surgeon and

orthodontist when undertaking such procedures

• Extraction

• Surgical uncovering of teeth

• Frenectomy

• Pericision

• Transplantation of teeth

• Corticotomy

Extractions are the most commonly undertaken minor

surgical procedures in conjunction with orthodontic therapy.

Extraction procedures carried out are :

Therapeutic extraction

Serial extraction

Extraction of carious teeth

Extraction of malformed teeth

Extraction of supernumerary teeth

Extraction of impacted teeth

Therapeutic extraction is undertaken as a part of full fledged

orthodontic treatment mainly to gain space.

• Prior to therapeutic extraction a thorough diagnostic exercise

is essential.

• Preoperative radiographs are a valuable aid in planning and

execution of extraction.

Features

Extraction should be as atraumatic as possible

Care should be taken to preserve the integrity of the alveolus.

Any break or loss of either buccal or lingual bony plates may

prevent ideal positioning of the teeth during orthodontic

therapy

Serial extraction is an interceptive orthodontic procedure

Usually initiated in the early mixed dentition period

Corrected by a procedure that includes the planned extraction

of certain deciduous teeth and later specific permanent teeth

in an orderly sequence and pre determined pattern to guide

the erupting permanent teeth in to a , more favorable

position.

Premature loss

Arch length –tooth material discrepancy

Lingual eruption of laterals

Canines erupting mesialy over laterals

Mesial drift of buccal segments

Flaring

Ectopic eruption

Labial stripping or gingival l recession usually of lower incisors

The most common teeth to be impacted other than third

molars are maxillary canine followed by premolars, and

maxillary second molars

Ectopically erupted

Adjacent teeth are in good contact

Any pathology associated with it

Causing pressure on root of standing tooth

Radiographic location of tooth should be undertaken.

During extraction care should be taken not to

damage adjacent teeth or roots.

The tooth is approached by a buccal or palatal flap

depending up on its location.

Supernumerary

odontomes

Supernumeraries should be extracted when:

in anterior maxillary region, it prevents eruption of the permanent incisors

Cause malpositioning of adjacent tooth

If erupted causing crowding and periodontal complications

Cyst associated with it

After careful elevation of flap , adequate amount of bone is

removed using rotary cutting instruments

.The impacted or supernumerary tooth is removed and the

extraction socket inspected for any pathological tissue.

The flap is repositioned and sutures are placed for a week.

The presence of impacted teeth in dental arch can cause minor

dental irregularities due to deflection of adjacent teeth.

Impaction of teeth usually occur as a result of arch length

discrepancy or presence of mucosal and bony barriers that

prevent their eruption

The most commonly impacted tooth is the maxillary

permanent canine.

In many cases it is possible for the orthodontist to guide the

impacted canine in to normal location in the dental arch after

adequate surgical exposure.

An un erupted canine may be a candidate for surgical exposure

if :

No sign of tooth even after 12 years of age

Adequate room in the arch

Un obstructed path of eruption

Radio graphically root is not dilacerated

Location of the tooth

Evaluation of favorability

Evaluation of space adequacy

Surgical excision and bone removal

Fixing orthodontic attachments

Exact location of impacted tooth has to be determined .

This can be done using tube shift or right angle technique.

Most impacted teeth present as a bulge corresponding to their location which should be examined clinically by inspection and palpation

In many cases the orientation of impacted teeth may be such

that surgical orthodontic guidance of tooth in to the arch

may not be possible.

The favorability should be examined prior to the procedure, it

is considered favorable whenever the apex of canine is closer

to its normal position.

When impacted tooth is guided in to dental arch adequate space

should be present for their normal alignment .

In many cases involving the impaction of permanent canine the

deciduous canines are over retained .

These teeth have to be extracted to accommodate the permanent

canine.

The crown of impacted tooth is exposed by excision of the

overlying soft tissue and removal of bone covering .

The bone should be removed up to maximum height of

contour.

In most cases of favorably impacted canines, once the soft tissue and bony tissue is removed , the canine erupt on its own.

In some cases orthodontic guidance for eruption of the teeth in to the arch may be required.

Attachments are placed on the impacted tooth to guide the erupting tooth in to the arch

A metal crown with a hook

A celluloid crown with an attachment bonded to it.

Bondable orthodontic brackets or button

A ligature wire is wound around the attachment and the other end is tied to a removable or fixed orthodontic appliance.

The wire is gradually tightened at regular intervals to guide the erupting tooth.

Frenectomy is a surgical procedure performed to excise the

frenum and remove the deeply embedded fibrous tissue.

It may be a labial frenectomy and lingual frenectomy.

Two school of thoughts are :

i. it should be performed before orthodontic treatment

ii. It should be done after orthodontic treatment as it reduces

risk of scar tissue that prevents the closure of diastema

Indications: when a median diastema is being caused or held open by a thick, short and fibrous labial frenum which is attached to the incisive papilla.

Sometimes this frenum may insert in the inter maxillary suture area on the palatal aspect. When tension is applied to the frenum , incisive papilla should blanch.

Frenectomy usually done only after eruption of permanent

lateral incisors and canines fails to close the midline diastema

.

It can be done either before or after appliance therapy has

approximated central incisors.

The purpose of frenectomy is to eliminate the fibrous tissue

between the roots of the central incisors so that there is no

obstruction to approximation of these teeth by appliance

therapy.

Local anesthetic is infiltrated on either side of the frenum and

an assistant holds the lip outwards and forward while exerting

pressure on the lateral aspect , there by reducing the resultant

bleeding.

With no: 15 knife , incisions down to the bone are made on either side of the frenum , going in between the teeth and joined around the incisive papilla.

With a periosteal elevator ,underlying fibrous tissue is detached from the palatal bone and in between the teeth, This releases the frenum , which is left attached to the lip at its anterior end.

The band of tissue connecting the tongue to the floor of the mouth is called the lingual frenum or frenulum.

Occasionally this frenum might be congenitally short, thick, or tight , or may extend too far down along the tongue or the gum.

An unusually thick , large, or tight lingual frenum can

seriously constrict the movement of the tongue and this

condition called

“ tongue tie” or ankyloglossia.

Children may have difficulty breast feeding as infants and may

later develop lisping.

The patient is unable to clear away food from the roof of the

palate and from labiobuccal sulci

Occasionally , irregularity

of the lower incisors may develop .

Some patients may develop an open bite because of the pull

of the frenum on the jaw and tongue thrusting.

In edentulous patients the frenum may interfere with the fit

of the lower denture causing its displacement every time the

tongue moves.

The tongue acquires a heart shape when raised .

The patient cannot extend tongue out to a point and it curves down when extended.

An unusually short range of tongue extension may indicate the need for a lingual frenectomy.

A frenectomy is performed using either scalpel or a carbon

dioxide laser .

The surgeon excises the frenum or performs a

Z – plasty in order to

mobilize the tongue.

Pericision or circumferential supracrestal fibrotomy as it is

often called a minor surgical procedure that is undertaken to

counter the relapse tendency of the stretched gingival fibers.

Pericision involves surgical sectioning of these fibers by

passing a sharp narrow scalpel through the gingival sulcus

around the tooth to a depth of 2 mm apical to the alveolar

crest.

Pericision is generally undertaken as an adjunctive retention

procedure after the correction of rotations.

Under LA a no 11 knife is passed through gingival sulcus up to

crest alveolar bone

Cuts are made inter proximally on each side of a rotated tooth

and along the labial or lingual gingival margin

Transplantation of teeth has been advocated as an alternative

to other methods of treatment of impacted teeth.

It may be a good alternative for the adult patient who cannot

undergo conventional orthodontic movement of an impacted

tooth.

The advocated technique is a careful wide exposure of the

impacted tooth. .

The tooth is then moved in to its position with in the dental

arch and is stabilized with a segmental orthodontic

appliance.

Endodontic treatment ,if necessary is rendered 6 to 8 weeks

after the surgical procedure initially using a calcium

hydroxide paste.

Then a conventional root canal filling is done 1 year later.

Teeth may be transplanted from one position to another in

the dental arch .

Corticotomy is a surgical procedure usually undertaken in

patients having dental proclination with spacing .

This technique involves the sectioning of the dentoalveolar

region in to multiple small units to fasten orthodontic tooth

movement.

Labial flaps are raised and interdental bony cuts are made

parallel to the long axis of teeth

Done in young adults to reduce the duration of appliance

therapy

Rapid movement of one or more teeth

These cuts may be joined together by a horizontal bony cut above the apices of the roots.

Care should be taken not to totally separates the individual units.

Following the surgery ; orthodontic tooth movement is initiated using fixed appliance.

Adults with skeletal maxillary constriction

RME is not possible in this patients because of fusion of mid

palatal sutures

A jackscrew expansion device is cemented before surgery

followed by corticotomies are performed

Mid palatal sutures are osteotomized

Activate jackscrew

Expansion carried out in small increments

A stabilization period of 6 weeks for bony consolidation to

occur

Only through team effort that the multifaceted problems can

be successfully controlled.

To accomplish optimal orthodontic treatment a combined

effort of oral and maxillofacial surgeon and orthodontist is

essential