Minor surgical procedures in Orthodontics

An overview of the minor surgical procedures in Orthodontics for undergraduate students.

1. MINOR SURGICAL PROCEDURES

2. contents INTRODUCTION CLASSIFICATION MINOR SURGICAL PROCEDURES EXTRACTION SURGICAL UNCOVERING OF IMPACTED TOOTH FRENECTOMY CORTICOTOMY PERICISON OTHER PROCEDURES CONCLUSION REFERENCES

3. INTRODUCTION Surgical orthodontics is a term that refers to surgical procedures carried out as an adjunct to or in conjunction with orthodontic treatment. The role of these surgical interventions is to: To eliminate an etiologic factor To improve the aesthetics and function of the patient To correct severe dento -facial abnormalities that cannot be satisfactorily treated by growth modification procedures or orthodontic camouflage. To facilitate and hasten orthodontic treatment Help stabilize post orthodontic results To prevent relapse To prevent or correct periodontal problems

4. CLASSIFICATION

5. CLASSIFICATION MINOR PROCEDURES Extractions A. Therapeutic extraction B. Serial Extraction C. Extraction of carious teeth D. Extraction of malformed teeth E. Extraction of supernumerary teeth F. Extraction of impacted teeth 2. Surgical uncovering of teeth 3. Frenectomy 4. Pericision 5. Transplantation of teeth 6. Corticotomy 7. Transpositioning of teeth 8. Removal of cyst and odontomes MAJOR PROCEDURES Orthodontic/ Orthognathic surgeries 2. Cosmetic surgeries 3. Surgical correction in cleft lip and palate 4. Surgical assisted rapid maxillary expansion (SARPE) 5. Distraction osteogenesis

6. CLASSIFICATION SOFT TISSUE PROCEDURES Pericision Frenectomy Gingivectomy/ Gingivoplasty Removal of soft tissue barrier Dentoalveolar procedures Corticotomy Wilckodontics Orthodontic implants Transplantation of teeth Trans positioning of teeth Removal of cysts and odontomes Surgical exposure of impacted tooth EXTRACTIONS A. Therapeutic extraction B. Serial Extraction C. Extraction of carious teeth D. Extraction of malformed teeth E. Extraction of supernumerary teeth F. Extraction of impacted teeth OTHER PROCEDURES Lasers Cryosurgery Electocautery

7. MINOR SURGICAL PROCEDURES

8. EXTRACTION Extractions are the most commonly undertaken minor surgical procedures in conjunction with orthodontic therapy. Extraction performed as a part of orthodontic therapy includes :

9. THERAPEUTIC EXTRACTION 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. THE NEED FOR EXTRACTION Arch Length – Tooth Material Discrepancy Correction of Sagittal interarch Relationship Extraction for the relief of crowding Abnormal size and form of teeth Skeletal jaw malrelations

10. CHOICE OF TEETH FOR EXTRACTION Choices of teeth to be extracted depends on local conditions which include:

11. SERIAL EXTRACTIONS Serial extraction is an interceptive orthodontic procedure usually initiated in the early mixed dentition when one can recognize and anticipate potential irregularities in the dento -facial complex and is 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 into a more favourable position.

12. EXTRACTION OF SUPERNUMERARY, IMPACTED AND ANKYLOSED TEETH The presence of supernumerary, impacted and ankylosed teeth are important local causes of malocclusion. The most commonly seen supernumerary teeth are the mesiodens . Supernumerary teeth are also occur in the incisor, premolar and molar region. Impactions in the maxilla generally occur in the canine region.

13. INDICATIONS In the anterior maxillary region, supernumeraries may prevent eruption of permanent incisors. May cause pressure on the root and lead to mispositioning of adjacent teeth. If erupted, can be the cause for crowding in the arch or may cause periodontal complications. There may be a cyst associated with them.

14. TECHNIQUE Prior to the removal of these teeth their exact location and their relationship with adjacent structures should be ascertained by radiographs. The tooth is approached by a buccal or palatal flap depending upon its location. After careful evaluation of the flap, adequate amount of bone is removed using rotary instruments. During the extraction procedure, care should be taken not to damage the adjacent teeth or roots. The impacted or supernumerary tooth is removed and the extraction socket inspected for any pathological tissue. The flap is repositioned and sutures placed for a week.

15. SURGICAL UNCOVERING OF IMPACTED TEETH Impaction of teeth usually occurs as a result of arch length discrepancy or presence of mucosal or bony barriers that prevent their eruption. The most commonly impacted tooth is the maxillary permanent canine. Impaction of teeth usually occurs due to: Arch length discrepancy Presence of mucosal and bony barriers Abnormal developmental position of tooth germ Retained deciduous teeth Deflection of canine during eruption Genetic predisposition

16. INDICATIONS An unerupted canine may be a candidate for surgical exposure if: There is no sign of the tooth even after 12 years of age. Adequate room in the arch is present or can be created orthodontically or by extraction of some other tooth. Potential path of eruption is unobstructed by other teeth. The apex of canine comes as close to normal as possible after eruption so that it does not look unsightly. Radiographically, the root is not dilacerated. Labial impaction of a maxillary canine is due either to ectopic migration of the canine crown over the root of the lateral incisor or shifting of the maxillary dental midline, causing insufficient space for the canine to erupt.

17. MANAGEMENT OF AN IMPACTED TOOTH The following steps are undertaken in the management of an impacted tooth: Location of the tooth Evaluation of the favourability Evaluation of space adequacy Surgical excision and bone removal Fixing orthodontic attachments

18. RADIOGRAPHIC EXAMINATION Presence of impacted canine/canines Judging the amount of root resorption of remaining/ retained deciduous canines. Resorption of either permanent central or lateral incisors. Cystic changes in the canine follicle Presence of apical dilaceration Displacement of adjacent teeth Axial inclination of the impacted tooth in relation to the horizontal and vertical planes. The position of apex of canine and its relationship to the first premolar.

19. RADIOGRAPHIC EXAMINATION Periapical radiographs taken by parallax method. Occlusal view of maxilla will also help us in locating the position of the canines. P.A. view and lateral cephalograms will help us to know about the degree of palatal or buccal displacement. CT can be suggested in specific cases of palatally impacted canine. CBCT is the most preferred method to diagnose and localize an impacted tooth.

20. Location of the tooth To determine the exact location of impacted tooth, Clark’s tube shift technique or right angle technique using two films. Clark’s tube shift technique – A radiographic procedure used for localizing impacted teeth to determine their relative antero-posterior position. If the two teeth or a tooth and a foreign object are located in front of one another relative to the x-ray beam, they will appear superimposed on one another on a dental radiograph.

21. EVALUATION OF FAVOURABILITY In many cases the orientation of the impacted teeth may be such that surgical orthodontic guidance of the tooth into the arch may not be possible. The favourability should be examined prior to undertaking the procedure. It is considered favourable whenever the apex of the canine is close to its normal position.

22. EVALUATION OF SPACE ADEQUACY When the impacted tooth is guided into the dental arch, adequate space should be present for its normal alignment. The deciduous canines are over-retained and have to be extracted to accommodate the permanent canines. In certain patients, the space intended for the permanent canine may be lost by migration of the adjacent teeth. The space is created by consolidating the rest of the teeth and possibly extracting a premolar.

23. SURGICAL EXPOSURE Correction of unerupted tooth into proper position consist of 3 stages: Pre-surgical phase Surgical phase Post-surgical – Method of attachment and mechanical alignment

24. SURGICAL EXCISION AND BONE REMOVAL The technique of surgical exposure is combined with the placement of an orthodontic attachment to the tooth, allowing active guidance of the impacted tooth into an ideal position. The crown of the 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. There are 4 techniques for uncovering a labially impacted maxillary canine GINGIVECTOMY FLAP/CLOSED ERUPTION TECHNIQUE APICALLY POSITIONED FLAP TUNNEL TRACTION

25. GINGIVECTOMY Simple excision of the gingiva over the impacted teeth can be accomplished with a sharp blade. Indicated when there is a wide zone of attached gingiva. Bone removal is not needed, and one-half to two-thirds of the crown can be exposed, leaving at least a 3 mm gingival collar. The most common area where this technique may be employed is over the labially impacted maxillary canine. This technique is simple and quick to carry out but sacrifices healthy attached gingiva and may increase the risk of detrimental changes in the periodontal tissues.

26. FLAP/CLOSED ERUPTION TECHNIQUE This technique is best used with high labially impacted teeth and teeth that are impacted in the mid-alveolar area. TECHNIQUE: An incision is made on the crest of the gingiva and buccal or lingual flaps are reflected. Appropriate bone removal is accomplished, and a bracket or chain is attached to the impacted tooth. The flaps are returned to their original location for complete closure. The chain passes under the flap, exits at the mid-crestal incision area, and is attached to the archwire .

27. FLAP/CLOSED ERUPTION TECHNIQUE Disadvantages: Time consuming Once the flap has been replaced direct inspection of the tooth cannot be made. Debonding of attachment may therefore take some time to detect and rebonding the attachment is difficult. The tooth may be difficult to isolate for acid etching and bonding technique.

28. APICALLY POSITIONED FLAP Technique: A split thickness flap is reflected from the area adjacent to the impacted tooth. Appropriate bone removal is accomplished, and the flap is sutured apically, exposing about two-thirds of the crown. This technique is most often employed on simple labially impacted teeth. Advantages: Accurate control of the amount of keratinized gingivae postoperatively and helps maintenance of the mucogingival complex, which will help ensure a healthy long-term prognosis for the tooth. Tooth can be easily inspected at follow-up appointments. Debonding of the attachment is readily detected and rebonding attachments is relatively simple.

29. TUNNEL TRACTION This technique was introduced by Crescini et al in 1995. This technique is indicated when the permanent canine is located very high and the deciduous canine is retained. Technique: Reflecting a full thickness mucoperiosteal flap over the impacted canine. The cortical bone over the impacted canine is cut off to expose ½ to 2/3 of its crown. Care should be taken not to expose the cemento -enamel junction. An orthodontic attachment is bonded over the exposed canine and a ligature wire wrapped to it.

30. TUNNEL TRACTION Technique: The deciduous canine is now extracted and a tunnel is created by cutting off any bone that covers the incisal tip of the canine. The ligature wire that is attached to the bracket exits through the tunnel and is ligated to the arch wire for traction. The flap is sutured back in place. Therefore the tunnel formed can be said to be an extension of the socket of deciduous canine which provides a pathway for the permanent canineto erupt.

31. FIXING ORTHODONTIC ATTACHMENTS In most cases of favourably impacted canines, once the soft tissue and bony tissue is removed, the canine erupts on its own. In some cases, orthodontic guidance for eruption of the teeth into the arch may be required. Attachments are placed on the impacted tooth to guide the erupting tooth into the arch. Some of the attachments that can be placed on the impacted canine are: A metal crown with a hook A celluloid crown with an attachment bonded to it Bondable orthodontic brackets or buttons Gold chain with a mesh base

32. ALTERNATIVE METHODS OF MANAGING IMPACTED MAXILLARY CANINES Leave it in situ/ Leave alone: (Ericson and Kurol , 1988) If the canine is asymptomatic without evidence of any infection or pathology, the tooth is left as such in a well-aligned arch. Periodic annual review is necessary. Extraction: Tooth id unfavourably displaced and cannot erupt normally or with orthodontic assistance. Tooth showing signs of pathology Tooth which causes resorption and displacement of adjacent teeth.

33. ALTERNATIVE METHODS OF MANAGING IMPACTED MAXILLARY CANINES Transplantation In carefully selected cases, it is possible to transplant the canines avoiding a prosthetic replacement. Precautions to be taken while transplanting canines: Adequate space must be available Success of transplanted tooth is more likely, when the apex is wide open. Root should not be handled. Ankylosis and resorption of the root may occur.

34. FRENECTOMY Frenectomy is a surgical procedure to excise the frenum and remove deeply embedded fibrous tissue. Many cases of midline diastema are believed to caused and maintained by maxillary labial frenum. The presence of a thick, fleshy and fibrous frenum prevents the two maxillary central incisors from approximating each other. In these patients, the frenal tissue may cross over and et attached in the inter-maxillary suture area on the palatal aspect.

35. LABIAL FRENECTOMY The presence of median diastema may be associated with a low attachment of the labial frenum. Labial frenum may sometimes merge with the incisive papilla. A V-shaped radiographic appearance of the interproximal bone or a bony interdental notch between the maxillary central incisors is a diagnostic sign for high frenal attachment as the cause for diastema. Abnormal frenal attachments are diagnosed by a blanch test. When the upper lip and frenum are stretched, the tissue between the central incisors moves and is blanched.

36. LABIAL FRENECTOMY The timing of frenectomy is crucial. According to some, frenectomy should be performed prior to orthodontic closure of the midline diastema. According to another school of thought, frenectomy should be performed after space closure as it reduces the risk of scar tissue formation that can prevent closure of the midline space.

37. TECHNIQUE 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. Region around the frenum is wiped with cotton or gauze and excision margins are marked. Local anaesthetic is infiltrated on either side of frenum. The lip is held outwards and forwards using forefinger and thumb on either side of frenum by an assistant. This not only produces traction, but also helps to reduce the perfusion of surgical area resulting in less intraoperative bleeding.

38. TECHNIQUE With a no. 15 blade, 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, the underlying fibrous tissue is detached from the palatal bone and in-between the teeth. This releases the base of frenum, which is left attached to the lip at its anterior end. This is then excised and the wound closed after clearing all fibrous tissue from the bone. Residual defect on the gingiva is covered by a periodontal pack. Sutures are removed on the 7 th day. Healing is normally uneventful.

39. PRECAUTIONS TO BE UNDERTAKEN The frenum should not merely be clipped. It should be totally excised to the bone level. Any palatally attached fibrous tissue should be removed. Fibrous tissue attached to the inter-maxillary suture area should be removed. The mucosa of the lip is undermined to prevent reattachment of the fibrous tissue. Frenectomy should be done only after the eruption of permanent lateral incisors and canines fails to close the median diastema.

40. LINGUAL FRENECTOMY The band of tissue connecting the tongue to the floor of mouth is called the lingual frenum or frenulum. Thick, large or tight lingual frenum can seriously constrict the movement of tongue and this condition is called “tongue-tie” or ankyloglossia which also contributes to diastema. This has to be divided horizontally near the alveolar ridge and sutured vertically. An abnormally high attachment of the mandibular labial frenum can cause recession of the gingiva in that area. It exerts a strong pull on the free and attached gingiva leading to recession in the lower anterior region. If gingival recession is present, reposition flap or free gingival graft is recommended along with frenectomy.

41. CORTICOTOMY Corticotomy is a surgical procedure usually undertaken in patients having dental proclination with spacing. This technique involves the sectioning of the dento -alveolar region into multiple small units to hasten orthodontic tooth movement. This procedure is usually carried out on the anterior maxillary teeth in young adults when the duration of appliance therapy needs to be shortened. It is indicated in patients with generalized spacing due to macrognathia and in median diastema without any other features of malocclusion.

42. TECHNIQUE: Large labial and palatal mucoperiosteal flaps are raised to expose both the labial and palatal cortices of the teeth to be moved. Vertical unicortical cuts of predetermined width are made with a thin bur (no.701) on either side of each tooth. The apical ends of these cuts are joined by horizontal cuts through the compact bone alone thus leaving the teeth to be aligned supported by cancellous bone. Care should be taken not to totally separate the individual units. The flaps are replaced and sutured. Following the surgery, orthodontic tooth movement is initiated using fixed appliances. Retainers are required for a period of 6 months to stabilize the result.

43. CORTICOTOMY-ASSISTED ORTHODONTIC TREATMENT (CAOT) The development of CAOT overcame many limitations in the orthodontic treatment of adults. ADVANTAGES: Reduced treatment time Enhanced expansion Differential tooth movement Increased traction of impacted teeth Increased post-orthodontic stability

44. APPLICATIONS OF CAOT Corticotomy and osteotomy are used in orthodontics to resolve crowding in a shorter period of time. Accelerate canine retraction after premolar extraction. Corticotomy –facilitated orthodontic treatment is found to result in better post-treatment stability compared to conventional orthodontic treatment. The improved stability is attributed to the increased turnover of tissues adjacent to the surgical site.

45. Accelerated osteogenic orthodontics (AOO)/ wilkodontics Wilcko developed a technique called accelerated osteogenic orthodontics (AOO) or periodontically accelerated osteogenic orthodontics (PAOO). This technique is similar to conventional corticotomy except that selective decortication in the form of lines and points is performed over all the teeth that are to be moved. In addition, a resorbable bone graft is placed over the surgical sites to augment the confining bone during tooth movement. After a healing period of one or two weeks, orthodontic tooth movement is started and then followed up using a faster rate of activation at two week intervals.

46. PERIODONTALLY Accelerated osteogenic orthodontics (PAOO) Indications: Class I with moderate to severe crowding Class II with extraction or expansion Mild class III cases To facilitate eruption of impacted teeth Molar intrusion and open bite correction Molar uprighting Molar distalization

47. PERIODONTALLY Accelerated osteogenic orthodontics (PAOO) Contraindications: Severe class III cases Active periodontal and gingival recession Abnormal skeletal relationship between the jaws Patients with uncontrolled DM, compromised immune system and on long term use of medication such as anti-inflammatory, immunosuppressive or steroids Uncontrolled osteoporosis or other bone disease Patients who are taking medication that slow down bone metabolism such as bisphosphonate and NSAIDS

48. PERICISION Synonyms: Supracrestal fibrotomy, Circumferential Supracrestal fibrotomy (CSF), Sulcus slice procedure, Edwards procedure This procedure is carried out to minimize the extent of rotational relapse of teeth. This method was developed by Edwards.

49. PRINCIPLE It is generally assumed that a stable position of the teeth in the dental arch after orthodontic tooth movement can only be established when the connective tissues of the gingiva have been allowed to adapt to the newly created situation. Suprecrestal gingival fibers ( Transseptal and alveolar crest group of gingival fibers) of an orthodontically moved tooth get stretched and undergo readaptation very slowly. The pull of these fibers is a major factor in relapse. Percision involves elimination of the pull of elastic Supracrestal gingival fibers by sectioning these fibers. Teeth are held in the corrected position when the fibres heal, thereby reducing the relapse caused by elasticity of the gingival fibers.

50. TECHNIQUE Edward’s technique: Circumferential Supracrestal fibrotomy (CSF) Under local anaesthesia, a No. 15 BP blade is inserted into the gingival sulcus upto the alveolar crest of the bone. Blade is kept parallel to the tooth surface and is passed around the circumference of the tooth. This severs the fibers connecting tooth to the gingival soft tissues. Cuts are made interproximally on each side of the rotated tooth and along the labial or lingual gingival margin.

51. ALTERNATIVE TECHNIQUE Papilla dividing procedure: Vertical incisions are made in the centre of each gingival papilla 1-2 mm below the margin. This reduces the chance of reduction of height of gingival attachment after the surgery. TIME OF SURGERY The teeth should be held in good alignment during the gingival healing. Therefore surgery should be done few weeks before the removal of active orthodontic appliance. Retainer must be given immediately after debonding of the active appliance.

52. OTHER PROCEDURES TRANSPOSITIONING OF TEETH/ AUTOTRANSPOSITIONING/ SURGICAL REPOSITIONING OF TEETH TRANSPLANTATION : Technique wherein a tooth is reimplanted after being removed into a modified or newly created socket.

53. OTHER PROCEDURES - lasers LASERS LASER stands for Light Amplification by Stimulated Emission of Radiation. Laser applications in orthodontics Diagnosis : To detect the caries To assess the tooth mobility Soft tissue applications For hemostasis To excise the lesions For incision and drainage of abscess For the removal of opercula on third molar For the removal of redundant gingival tissue during the orthodontic treatment Hard tissue applications For caries removal For enamel etching For crown lengthening procedure Non surgical procedures For curing of materials For instrument sterilization

54. OTHER PROCEDURES - lasers Surgical Procedures For incisions For the exposure of impacted tooth For frenectomy Other applications Laser holography Laser spectroscopy 3D Laser scanning Laser orthopaedics Laser osseous surgery Laser welding and micro welding

55. OTHER PROCEDURES - lasers ADVANTAGES DISADVANTAGES During the surgery Less pain Minimal bleeding Better visualization A more sterilized environment Less damage to the adjacent tissues Laser cut is more precise than the surgical cut Reduced risk of blood borne, transmission of diseases It is not economical There may be chances of explosion It requires specially trained personnel After the surgery Less scaring Faster healing Minimum postoperative pain Reduced risk of postoperative infection Hazards Retinal burn if there is no protection Aerosols contamination and respiratory hazards Prolonged exposure to pulp causes irreversible pulp damage

56. OTHER PROCEDURES - electrocautery Electrocautery is a surgical technique which involves introducing high frequency current (usually 100 kHz) to the specific area of the body in order to remove unwanted tissue, seal off the blood vessels or to create a surgical incision. Orthodontic Indications: In case of long lingual frenum which can interfere with tongue movement and speech. In case of hyperplastic or low lying frenum which can disturb the path of eruption and also may cause gingival stripping. Gingival problems: In case of hyperplastic interdental gingiva which affects further orthodontic progress In case of fibrous gingiva which may interfere with normal eruption.

57. OTHER PROCEDURES - electrocautery Eruption problems In case of partially erupting teeth, that is waiting for erupting canine or other teeth in the oral cavity before it can be bonded and incorporated in fixed appliances. For clinical crown lengthening procedures Other uses It can used to cut the soft tissue to get access for the surgical site. It can also be used to seal off bleeding vessels during the surgery to keep the surgical site clean and reduce the blood loss.

58. OTHER PROCEDURES - electrocautery Advantages: It is economical, requires less chair time, and minimal patient discomfort. Surgical recovery is more rapid than the conventional surgeries, and there is reduced risk of infection. Limitations: Depending on the voltage used, the electrocautery can have varying effects on the patient’s body. Lower frequencies could cause twitching and cramps, which would be a serious problem. If electrocautery is not performed with safe equipment, the patient’s body can be potentially burned elsewhere.

59. CONCLUSION Very good orthodontic alignment and stability can be achieved by successfully combining orthodontics and surgery. As important advances in surgical technique and anaesthesia evolved for the surgical procedures, a major contribution by orthodontists in collaboration with surgeons was the creation of a common diagnostic, planning, and treatment scheme for use by both clinician groups in treatment of dentofacial deformities and other skeletal and dental problems.

60. REFERENCES ORTHODONTICS – THE ART AND SCIENCE (7 th Edition) – S.I. Bhalajhi TEXTBOOK OF ORTHODONTICS (3 rd Edition) – Gurkeerat Singh ORTHODONTICS (2 nd Edition) – Sridhar Premkumar TEXTBOOK OF ORTHODONTICS (3 rd Edition) – M.S. Rani