جامعة بابل | University of Babylon



DENTO-ALVEOLAR SURGERY: HELPING THE

ORTHODONTIST

Many minor oral surgical procedures, e.g. extraction of 4s or removal of 8s, are carried out at the

instigation of an orthodontist. This page concerns itself with the specific procedures of frenectomy,

pericision, tooth exposure, and tooth repositioning.

Frenectomy This is of value in closing a median diastema only if gentle traction on the upper lip and fraenum produces blanching in a palatal insertion around the incisive papilla. It follows that the

excision of the frenum must include those fibrous insertions, which leaves a raw area of alveolus

after excision⎯this can be dressed with Surgicel, BIPP, or a periodontal pack. It is a different

operation from preprosthetic fraenectomy and is performed for a different reason.

Pericision is simply incising supra-alveolar periodontal fibres to prevent relapse when derotating

teeth.

Tooth exposure Orthodontic traction is the treatment of choice for malpositioned, unerupted canines

and incisors if the apices are in good position for eruption. The essential aspect of the operation is

to remove any sacrificable impediments to tooth movement. Bonding an eyelet and gold chain or

other bracket technique has a lower incidence of reoperation, but needs the orthodontist in theatre.

Technique Palatal teeth are exposed by a palatal flap. Remove bone carefully with chisels, expose

the greatest diameter of the crown and the tip. (Moving the tooth is counter-productive, therefore

don't do it.) Excise palatal mucoperiosteum generously, it grows back; bond a bracket if you're

going to. Firmly pack the wound with, e.g., Whitehead's varnish and ribbon gauze and secure, or

use an acrylic dressing plate with periodontal paste dressing. Close the remainder of the flap with

vertical mattress sutures. Buccally located teeth are approached by a buccal flap, in order to

preserve attached gingiva, and bonding should be done at operation. The flap can be repositioned

coronally with the elastics or chain tunnelling subgingivally. Teeth within the arch are approached

buccally removing crestal bone as needed.

Tooth repositioning (transplantation) Although there are claims of success rates as high as 93%,

few people match this and most would transplant only when exposure and orthodontic movement

were rejected. The most commonly transplanted tooth is the maxillary canine. It is essential to

measure the available space and compare this with the erupted contralateral tooth or a good X-ray

estimation, as it is not acceptable to grind down healthy teeth at operation to accommodate the

retrieved tooth. If the tooth appears to be too big for the available space then orthodontic Rx is

required to create space. As this is often the reason the patient rejected exposure, an impasse is

sometimes reached.

Technique The tooth is exposed by buccal or palatal flap, and once it is certain that it can be

removed atraumatically, the deciduous tooth, if present, is extracted and a new socket surgically

prepared with a bur. The tooth is reimplanted without force, the flaps sutured, and a close-fitting

but not cemented splint placed. Functional splinting is continued for 7-10 days and the tooth rootfilled

as soon as possible after surgery. Regular follow-up is essential to allow early detection of root

resorption.

[pic]

A Outline (heavy black line) of the incision for a palatal flap raised to expose

a buried right maxillary canine.

p Position of the palatine arteries. Do not attempt a palatal 'relieving' incision;

exposure is achieved by the length of the envelope flap.

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Operation

Operation site

The attachment of the fraenum is demonstrated by

traction, with a finger in the sulcus on either side.

The cooperation of an assistant, using the fingers of both

hands to grasp and evert the lip firmly in this way, is

essential both to provide retraction and to help reduce

bleeding by occlusion of the labial vessels.

Excision

The fraenum is grasped in a curved haemostat.

I t is released by an incision on either side of its base.

Excision is completed by running the scalpel edge down

the back of the haemostat.

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