Dento alveolar surgery

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.



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.