issues following surgical exposure
Young patients who are about to undergo surgical exposure of an impacted tooth need to be informed how the procedure may affect their daily life in terms of pain, function, speech and the several other aspects that involve the oral cavity. The risks and benefits of the intended treatment must be clearly set out. Patients are often apprehensive at the thought of surgery, particularly if they are young and healthy with little or no previous experience of surgical procedures. The incidence and magnitude of these challenges are all part of the post‐surgical follow‐up, of which patients and their parents must be apprised. These aspects of the procedures constitute information that the law requires to be explained to them, in order for them to sign a statement of informed consent. While this is true of all types of orthodontic treatment, it is particularly so where surgery is involved.
A number of articles have recently appeared in oral surgery journals regarding these parameters within the context of the extraction of third molars. However, it is a matter of surprise that there is a significant paucity of published works that relate to quality‐of‐life (QoL) issues in the context of the surgical exposure of impacted teeth. The result has been that the information available to both clinicians and patients is often based on a single anecdotal episode or on the biased reports of individuals who have themselves experienced some form of oral surgery. Information thus gleaned is notoriously unreliable and will rarely have any application to the particular surgical exposure then planned.
This lack of professional information was the motivating factor for the prospective clinical studies that were undertaken in Jerusalem, to quantitatively assess the various aspects of QoL consequential to the performance of both open and closed surgery [42–44].
For the purpose of the QoL study, two groups of patients were assembled. One group included young patients who were scheduled for open surgery and the second group for closed surgery. On the day the exposure was performed, each patient was presented with seven identical questionnaires and was instructed to complete one of the questionnaires on each post‐treatment day, for each of the following seven days. Information was then collected from the answers regarding pain, oral function, general disability, limitation in eating, absence from school and related parameters. The results for the group of patients who had had open exposure were then analysed and compared with those for the patients who had undergone closed exposure.
In general, it was found that full recovery from an open eruption exposure required five days, whereas only three days were required for a closed procedure. It was particularly observed that, in the case of the longer recovery period (the open technique), there was a higher level of pain, greater difficulty in eating and swallowing and an increased need for analgesics. More specifically, it was found that there was much greater discomfort with the open exposure in the case of a palatally impacted canine, especially if bone removal had been performed. However, it is noteworthy that exposure of impacted teeth with a buccal approach resulted in a high level of discomfort, regardless of the surgical method that had been employed. It may be speculated that this was due to the fact that paranasal and oral musculature is severed during buccal procedures and the surgical flap is sited in highly mobile oral mucosa.
Table 5.1 summarizes the effects on QoL issues immediately post treatment. We can see the advantages and disadvantages of complete flap closure (healing by primary intention) compared with the alternative open exposure techniques, in which the opening in the tissue over the impacted tooth is maintained by reducing the size of the flap and packing the wound or by repositioning the flap more apically (healing by secondary intention).
Cooperation between surgeon and orthodontist
From the discussion in this chapter so far, it will have become quite clear that there are severe limitations in the ability of the surgeon to single‐handedly treat the cases discussed. We have sought to demonstrate that, in most situations, the inclusion of orthodontic procedures offers a better chance of success. Indeed, today orthodontists are playing an increasingly important role in the initial stages of the treatment of impacted teeth, in particular by providing the traction that is necessary to encourage eruption. In many of the cases where teeth were previously felt to have poor prospects for eruption, the contribution of the orthodontist to the ultimate successful result has been the ‘game changer’.
Once the oral surgeon has made the impacted tooth accessible, its destiny is largely dependent on the ability and the ingenuity of the orthodontist, to apply light traction in an appropriate direction, efficiently and with the appropriate means. If orthodontic treatment is available to the patient, the other highly empirical and suspect procedures listed at the beginning of this chapter, which may otherwise be suggested by the surgeon, become superfluous. There is no evidence that suggests that these procedures may improve the opportunity for orthodontic resolution, without thereby causing consequential harm.
Fig. 5.11 A case of bilateral palatal impaction of maxillary canine treatment with the closed eruption surgical technique. (a) Anterior section of the pre‐treatment panoramic view to show canines almost contacting in the midline. (b) Panoramic view of the post‐treatment result. (c) The treated result seen 14 years post treatment with relapsed incisor overjet and overbite. (d) Close‐up intra‐oral view of the teeth from the labial side, showing the canines to be indistinguishable from their neighbouring teeth in terms of their crown length, gingival contour and excellent appearance. (e) Clinical view of the palatal sides of the two canines, 14 years post treatment, to show normal gingival contour, normal crown length and no recession. No reparative periodontal procedures were performed after the original closed surgical exposure. (f) Periapical radiographs of the teeth showing excellent bone support and pattern.
Fig. 5.12 (a) Mild palatal displacement of the right maxillary canine located very high in the line of the arch (Group 3 canine) and treated with full‐flap closure on the buccal side (closed eruption technique). (b, c) The right and left sides are indistinguishable at the completion of treatment.
It may therefore be concluded that, with respect to the treatment of impacted teeth, the aims of the oral surgeon should be limited to:
Provision of access to the buried tooth.
Elimination of any obstruction from the tooth’s eruptive path, such as supernumerary teeth, odontomes or thickened overlying mucosa.
Maintaining haemostasis, thereby enabling active participation of the orthodontist at surgery in bonding an attachment to the exposed teeth, which is so critical in ensuring success.
In summary, it is our contention that the single most important aim of surgical involvement is to provide access to a tooth that is otherwise buried. This will enable the orthodontist to provide the means, in as simple a manner as possible, by which force may be applied to the tooth in question, through several subsequent visits over a longish time‐span. For this to happen, an attachment has to be securely bonded and a firm ligature, or other form of intermediary, drawn to the exterior, to which steel wires, super‐elastic nickel–titanium wires, elastic ligatures
