Oral surgery and orthodontic for orthodontists by Almuzian

Oral surgery and orthodontic for orthodontists by Almuzian

• 1.
  Orthodontics and OralSurgery Impacted maxillary incisors Incidence/prevalence  The incidence of unerupted maxillary central incisor in the 5–12 year-old age group has been reported as 0.13% McPhee  In a referred population to regional hospitals the prevalence has been estimated as 2.6% DiBiase  In the premaxillary region, where there is a failure of eruption of the permanent incisors, the effects of supernumerary teeth have been reported variably at 28% and 38%.  Tuberculate supernumerary teeth are more likely to cause an obstruction than conical supernumerary teeth (1in 5 compared to 1 in 1).  In addition, 1/3 of compound odontomes and 1/2 of complex odontomes prevent eruption of teeth (compound odontomes are four times more common than complex odontomes).  In 54-78% of cases in which supernumerary teeth overlie the incisor, removal of the supernumerary will result in the permanent incisor erupting spontaneously within an average time of 16 months provided there is enough space Causes ofdelayed eruption Delayed eruption can be classified into two causative groups. Hitchen 1970 1. Hereditary A. cleft lip and palate
• 2.
  B. cleidocranial dysostosis, C.gingival fibromatosis. D. Supernumerary teeth , odontomes, E. abnormal tooth/tissue ratio, F. generalised retarded eruption, 2. Environmental A. Trauma B. early extraction or loss of deciduous teeth C. retained deciduous teeth, D. cystic formation E. endocrine abnormalities F. bone disease G. primary failure of eruption, H. Thick bone or tissue. Or can be classifiedinto localand generalby Fleming Managementof unerupted maxillary incisors EXAMINATION 1. History A. History of pain or trauma B. Family history 2. VISUAL EXAMINATION A. there is eruption of contralateral teeth that occurred greater than six months previously; B. both central incisors remain unerupted and the lower incisors have erupted greater than one year previously; or
• 3.
  C. there isdeviation from the normal sequence of eruption (eg lateral incisors erupting prior to the central incisor). D. Retained deciduous A E. Change in the color, angulation of the adjacent F. Availability of spacewith labial or palatal budges 3. Radiographs. A. A dental panoramic tomography and anterior occlusal radiograph can be taken for general assessment purposes. B. For detailed assessment of position it has been shown that the use of a horizontal parallax technique is better than vertical. C. More recently, cone beam computed tomography technology has become available for imaging the maxillofacial region and this can be used for the localization of impacted teeth, including incisors. Treatment depends on 1. Cause 2. Age 3. Inter and intra arch 4. Condition of the adjacent 5. Color and shape of the adjacent 6. Smile and gingival line 7. Position and angulation 8. Pt motivation 9. Clinician philosophy Treatment options 1. Accept
• 4.
  2. Segmental osteotomy 3.Transplant 4. Interceptive by removing retained deciduous tooth. 5. Create and maintain sufficient space  75% of incisors erupt spontaneously after spacecreation. Of these, 55% will align spontaneously while the rest will require some form of orthodontic alignment. 6. Surgical exposure and orthodontic alignment 7. Removal with spacemanagement by orthodontic appliance or without orthodontic appliance,  However, prolonged spacemaintenance can lead to significant alveolar bone loss in the affected region, making later implant placement more diffcult.  An alternative strategy, particularly in the younger child, is to allow spontaneous spaceclosure in the labial segment and then to open up spacewith fixed appliances prior to definitive restoration in the permanent dentition. Surgical exposure can be performed in 3 ways: I. Open exposure or Excisionof mucosa overlying the incisor (if the incisor is close to the surface and attached gingival can be preserved at the gingival margin) II. Apically repositioned flap. The exposure may need to be maintained using a non-eugenol based periodontal dressing. Whitehead’s varnish pack may cause discoloration of the underlying tooth. The short-term use of a chlorhexidine mouthwash should be prescribed to reduce gingival inflammation
• 5.
  III. Closed eruptionprocedure. A buccalflap is raised and an orthodontic attachment bonded to the incisor. A flap is raised and a bracket attached to a gold chain, customised bracket bonded to the incisal tip , steel ligature, magnet or elastomeric material is bonded to the tooth followed by replacement of the palatal flap. The least desirable way to obtain attachment is for the surgeon to place a wire ligature around the crown of the impacted tooth. This inevitably results in loss of periodontal attachment becausebone that is destroyed when the wire is passed around the tooth does not regenerate when it is removed and increases the chance of ankylosis. The bracket should be bonded as palatally as possible so that early fenestration does not occurleading to an unfavourable gingival contour. The flap is sutured backinto place.  It is likely that the position of the incisor, angulation, labiopalatal, amount of attached gingiva and bone will be the main factor influencing the choice of technique.  Ideally, a fixed orthodontic appliance should already be in place before the unerupted tooth is exposed, so that orthodontic force can be applied immediately. If this is not practical, active orthodontic movement should begin no later than 2 or 3 weeks postsurgically. Evidences for the type of exposure  Corn (1977) used a split thickness apically repositioned flap on 75 cases and found no marginal bone loss or gingival recession after orthodontic treatment.  Some authors believe the closed eruption technique to be the method of choice (Brin et al. 2002) in terms of aesthetic and periodontal outcomes as it is said to replicate natural tooth eruption.
• 6.
   Vermette, Kokichet al. (1995)examined the differences between surgicalexposure of incisors with an apically repositionedflap and using the closederuption technique. Photographic examination revealedvertical relapse of the exposedteeth in the apically repositionedgroup. It was concluded that those teeth exposedwith an apically repositionedflap have less aesthetic sequelaethan those treated using a closederuption technique. Problem with orthodontic treatment of impacted max incisor 1. Relapse 2. Failure of compliance 3. Resorption of the root of the adjacent teeth 4. Ankylosis 5. Intrusion of adjacnt 6. Pd probl DILACERATION Definition  as an angulation or deviation or sharp bend or curve in the linear relationship of the crown of a tooth to its root, root root, crown cown Prevalence, Antonious 2012  0.5-1.2%  Permanent more than primary and dentitions.  Male more than female  Maxilla more thn mand
• 7.
   Anterior morethan posterior  Unilateral more than bilateral  Mainly max central  (7% due to cyst, 22% trauma, 70% genetic) Aetiology A. 7% were associated with certain synergistic factors like CLP, cyst, sever infection, thick gingivae or bone, supernumerary teeth, cysts, tumours, odontogenic hamartoma, all of these cause deviation during development. B. 22% resulted from trauma C. 71% were developmental in nature. Stewart in 1978 Classification A. Crown B. the cement-enamel junction C. the root D. the root apex Clinical features of dilacerations 1. asymptomatic 2. Non-eruption of the responsible tooth, 3. the longer retention of the primary predecessortooth, 4. possible apical fenestration of the buccalor labial cortical plate, TREATMENT, Sandleret al 1988) 1. The dilacerated incisor may be brought into the line of the arch by exposure and closed technique.
• 8.
  2. Elective rootfilling and apicectomy may be undertaken where there is unfavourable labial root dilaceration. 3. If the malformation is severe, the incisor may have to be removed. Ankylosis of incisors The process ofshedding of a deciduous tooth is known to be a dynamic one in which the root undergoes resorption and repair at differing rates. Sometimes repair occurs at a greater rate than does resorption and the tooth become ankylosed to the alveolar bone Prevalence 1. 10.2% after traumatic injury 2. Male more 3. Maxilla more 4. Incisor more The following treatment options are available: 1. Periodical follow-up 2. reimplantation 3. extraction followed by orthodontic spaceclosure with lateral incisor as surrogate. 4. Extraction followed by placement of an osseointegrated implant if the patient has completed growth. 5. Autotransplantation of developing premolars to replace missing maxillary incisors has been documented ‘to provide physiologically sound results’. The most commonly selected tooth for transplantation is the lower second premolar. This has been documented to produce successfuloutcomes. 6. Osteotomy of the dentoalveolar segment with immediate repositioning.
• 9.
  de Souza 2009in Cochrane review found no evidence from RCTs about the comparative effectivenessofthe different treatment options for ankylosedpermanent front teeth. SUMMARY AND RECOMMENDATIONS OF RCSEng(yaqoobet al 2010) 1. Children up to nine years with incomplete rootdevelopment of permanent incisor:  Remove obstruction.  Do not uncover bone from unerupted incisor maintain integrity of follicle.  Create space if required.  Monitor eruption for 18 months – 80% erupt spontaneously  If exposure required then exposeminimally to eliminate soft tissue obstruction AND WAIT FOR 6 MONTHS. If tooth is still high, expose and bond bracket.  For bestaesthetics:  avoid excision of attached gingivae; and  avoid apically repositioned flaps. 2. Children above nine years with complete or nearly complete apex:  Remove obstruction.  Create space if required.  If permanent incisor high then monitor eruption for 12 months.  If tooth still unerupted at 12 months, expose and bond bracket as required.
• 10.
  3. Children referredlate (over 10 years):  Remove obstruction, expose and bond bracket at first operation. Toothis ectopic if malposition due to congenitalfactors or displaced by the presence ofpathology Impacted secondpremolars Aetiology  Similar to U1 causes  Early loss of primaries Management  IO by extraction of 4s to minimize the surgical approachand its related damages, care during radiographical assessment to evaluate the clinical condition of the impacted tooth which might be affected by hyploasia  Extraction of the 5s  Extraction of the 7s and molar distalization to allow 5s eruption, if the arch is well aligned