Treatment of impacted teeth
1. Introduction
Impacted teeth represent a major area of interest in odontostomatology, classified by the World Health Organization (WHO) as one of the global scourges in view of its high prevalence, frequently in relation to dentomaxillary disharmonies.
The generic term “impacted teeth”, in the broad sense, corresponds to an entity in its own right. It groups together different anatomoclinical diagnoses as many sub-entities, based on a varied semiology and whose nosological framework
was summarized by the Odontostomatologic Classification of Impacted Teeth
Their therapeutic approaches generally involve multidisciplinary collaboration where the surgical-orthodontic protocol is carried out
In close collaboration with periodontal surgery.
However, the placement of an impacted tooth is rarely a simple process; the patient should be warned of the duration of the treatment and the risks involved.
In order for the treatment decision to be made with full knowledge of the facts, he will need to be aware of the alternative solutions with their advantages and disadvantages in order to ensure his motivation and cooperation throughout the treatment.
2. General
2-1- Anatomo-pathological classification of impacted teeth.
See course Diagnosis of impacted teeth
2-2- Epidemiology of impacted teeth according to WHO.
See course Diagnosis of impacted teeth
3 – Different therapeutic aspects of included teeth
The treatment of impacted teeth can be divided into two main parts, the first is called preventive and includes different methods and means to prevent the occurrence of this inclusion and the second part is curative and aims to disinclude this tooth not yet on the arch after its usual eruption date.
The latter uses three treatment alternatives:
- Non-orthodontic solutions
- Exclusive surgical procedures
- Orthodontic-surgical treatment
3-1-Preventive treatment
The suspicion of impacted teeth will lead the practitioner to implement
preventive guidance
The aim is to awaken the eruptive potential as early as possible by lifting
of these obstacles to have a spontaneous eruption.
3.1.1 Extraction of supernumerary teeth and odontomas:
Supernumerary germs and odontomas must be diagnosed and avulsed early in order to prevent the risk of inclusions.
3.1.2. Maintain spaces:
Premature loss of the temporary tooth requires the possible placement of a space maintainer to prevent mesialization of the adjacent teeth, thus narrowing the extraction space and creating an obstacle to the eruption of the permanent tooth.
3.1.3 Development of an eruption corridor:
3.1.3.1. Avulsion of the temporary tooth
In order to modify the eruption path of the permanent tooth because a tooth is evolving
moves “in the path of least resistance.”
3.1.3.2. Transverse expansion of the maxilla:
Increasing the available space by orthopedic or orthodontic device (disconnector, or Quad helix).
3.1.4 Therapeutic closure of an inter-incisor diastema:
This closure is performed by upper labial frenum facing a deeply inserted frenum or avulsion of a mesiodens which is interposed between two centrals.
3-2-Curative treatment
3-2-1 Abstention
The reasons for abstention may come from the patient who refuses orthodontic treatment even though the impacted tooth, due to its position, does not present any threat to its environment.
This decision may also be linked to the impossibility of placing the included tooth, due to its position or its ankylosis and the desire to avoid an avulsion that would be too damaging at the bone level or of adjacent teeth.
Or even in the face of a general contraindication prohibiting any bloody act.
In all cases, regular monitoring will be necessary in order to detect any progressive pathology of the tooth left in place.
3-2-2 Extraction
This exceptional therapeutic decision requires evaluating the complex consequences of early extraction on the periodontal level
It is indicated when the included tooth is associated with nervous, infectious, mechanical, tumoral complications, also in the case of ankylosis or even significant coronoradicular angulation making its eruption impossible due to a horizontal axis.
Just as it can be indicated when it represents a danger for an adjacent tooth.
3-2-3 Exclusive surgical procedures
Conductive alveolectomy: this technique was developed by Chatellier in 1957.
It allows surgical creation of an eruption pathway by clearing any bony obstacle and eliminating the pericoronal sac. It is necessary that the space on the arch is sufficient or can be created, and that the release of the crown is possible without damaging the neighboring teeth. For the egression potential to be maximized, the conductive alveolectomy must be performed before the edification of the apical third.
This technique has the advantage of taking advantage of the natural and physiological eruptive potential of the tooth (retained tooth); nevertheless, the risks of ankylosis and/or bone resorption due to trauma to the periodontal ligament during bone resection should not be neglected.
Directional osteotomy allows to correct the position of the tooth without moving its apex. It is indicated when the canine is in a high position, with an apex close to its normal place. A flap from the lateral incisor to the first molar allows to expose the external table up to the two-thirds of the root then a mobilization with the syndesmotome is carried out with a minimal apical displacement and therefore a reduced risk of secondary mortification. But the risk of ankylosis always exists and the position of the canine often limits the indication of this procedure
Autotransplantation : this is the reimplantation in a newly formed alveolus at the physiological eruption site of the extracted included tooth. This technique is reserved when surgical-orthodontic treatment is impossible or when the included tooth is a threat to the roots of adjacent teeth.
It requires sufficient space on the mesiodistal and vestibulopalatine arch and should be reserved for immature teeth.
The major risk is the ankylosis-rhizalysis process which results in total resorption of the root within a variable period of 7 to 10 years.
3-2-4 Surgical-orthodontic treatment
This is the technique of choice for placing an impacted tooth in functional position; it offers the best results and long-term durability of the tooth. A space to be recreated on the arch is almost always essential; this often lengthy therapy is possible at any age but requires motivation and impeccable hygiene on the part of the patient.
Contraindications
Relatives : Unmotivated patient is a source of failure.
Absolutes
- The tooth is horizontal in the palatine process
- The cusp tip of the impacted tooth crosses the interincisal line.
- General illness.
Several processing phases will follow one another.
Pre-surgical orthodontic preparation:
Its purpose is to provide anchoring in order to pull the included tooth as soon as it is surgically released and to create a recipient site on the arch with an excess of 2 mm of space. This action can be obtained by a fixed multi-attachment device. This anchoring is most often provided by the entire arch but it can also be provided by specific mini-implants.
Surgical phase of disinclusion:
The surgical technique used to approach a tooth will depend on its spatial palatal or vestibular location in a low, medium or high position.
This phase goes through three stages:
A mucosal phase which consists of detaching a full-thickness flap if the tooth is intraosseous or only a semi-thickness flap if it is submucosal.
A bone stage, performed using a diamond ball bur mounted on a handpiece associated with a roughening tool, this step consists of the elimination of all the bone tissue that overhangs the included tooth and which creates an obstacle to its eruption. This is called bone clearance.
As for dental time, it describes the same steps as conventional bonding ; with the only difference that this bonding will be done on a dental surface belonging to an included tooth and per-operatively.
The following steps will be followed:
- Drying the tooth surface
- Etching with 37% orthophosphoric acid for 30 seconds
- Rinsing
- Drying
- Application of the binder
- Load the composite onto the back of the bracket
- Bonding the bracket to the exposed tooth surface
- Polymerization.
Treatment of impacted teeth
3.2.3.3. Post-surgical orthodontic phase
Its purpose is to place the included tooth on the arch .
The force transmitters must be connected to the force generators in an ideal position in order to guide the eruption of the tooth .
Its final positioning is always tedious because if it is easy to place the crown in its site, it is not the same for its apex.
Force transmitters
They represent the intermediary between the anchor point on the included tooth
and the fixed orthodontic device on which we will rely to pull this tooth.
In the form of a metal strand ligature ending in a hook or with eyelets, or in the form of an elastic chain.
Force generators:
These are anchoring devices, which through transmitters will deliver forces allowing the traction of the included tooth, we can use either auxiliaries such as the lingual arch or the transpalatal arch or miniscrews.
Once the tooth has appeared, it will be necessary to align it in the dental arch by continuing the multi-bracket fixed orthodontic treatment until optimal occlusion is achieved.
4. Conclusion
During the gradual formation of adult teeth.
This process can affect all teeth; however, therapy
will be different depending on the tooth considered.
This is why the diagnosis of any impacted tooth must be made as early as possible in order to monitor its development and implement
appropriate therapy at the right time. In addition, current diagnostic techniques and the increased precision of orthodontic mechanics are a valuable aid to therapeutic decisions.
In fact, if in the past the placement of impacted teeth consisted mainly of a gesture
surgical, the evolution of bonding techniques and cooperation between
periodontist and orthodontist helped improve results.
Alas! Not all impacted teeth can be put in place and it is up to the orthodontist to determine this in order to avoid unnecessary or even iatrogenic treatment.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.