Adrian Becker - Orthodontic Treatment of Impacted Teeth

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Adrian Becker

A brief history of surgery in relation to the treatment of impacted teeth

Aims of surgery for impacted teeth

Surgical intervention without orthodontic treatment

The surgical elimination of pathology

The principles of the surgical exposure of impacted teeth

Partial and full‐flap closure on the palatal side

A conservative attitude to the dental follicle

Pathological pressure necrosis

Quality‐of‐life issues following surgical exposure

Cooperation between surgeon and orthodontist

The team approach to attachment bonding

Prior to the 1950s, few orthodontists were prepared to adapt their skills and their ingenuity to the task of resolving the impaction of maxillary canines and incisors, many preferring to refer these patients to the oral surgeon. The decision regarding the method of treatment of a particular impacted tooth was usually made by the oral and maxillofacial surgeon (OMFS). It was OMFSs who considered the options, chose the one they felt was appropriate and stage‐managed the treatment process.

Surgeons would raise a flap, expose the tooth widely and only then make the decision whether to save the tooth or extract it. If, in their opinion, the impacted tooth could be brought into the dental arch, it would be left open to the oral environment with or without a surgical pack. If, in their judgement, this was unlikely to happen, they would extract the tooth on the spot and then write a note to that effect to the orthodontist. As can be imagined, many potentially retrievable, impacted teeth were thereby condemned to extraction.

The development of the role of the orthodontist in the rescue of impacted teeth was due to the realization that surgical treatment was just not enough. Whereas the elimination of the cause of the impaction and the provision of optimal space (by orthodontic means) did indeed provide a favourable environment to encourage autonomous eruption, it was clear that this alone was far from being universally successful. This led to the second realization: that orthodontic treatment alone was also not enough. It was acknowledged that, in order to achieve a more affirmative and quality result, with greater predictability, surgically afforded access would be required, together with the application of active and positive forces of traction/extrusion directly to the tooth.

From the early 1970s in the Hebrew University‐Hadassah School of Dental Medicine in Jerusalem, Israel, orthodontists joined forces with the OMFS at the chairside and in the operating theatre, to adapt and cement preformed canine orthodontic bands during the surgical procedure itself. This had been the procedure prior to the era of acid‐etching enamel and direct bonding of brackets. As a result, many more of these teeth were reclaimed and, in time, took their rightful place in the dental arch. However, in order to place a band, the entire crown needed to be dissected free of its dental follicle and clear of adjacent bleeding surfaces. This demanded radical surgery and efficient isolation of the tooth during the cementation process. Not every surgeon was willing to cooperate, thereby making the orthodontist much more selective in the choice of surgeon, particularly for difficult cases [1, 2].