It took a pandemic to conclude that dentistry is an essential service. What does that have to do with my topic today? Let’s back up a little, before this past winter, before the mayhem of corona virus hit New York and the United States. Back to when we were waking and greeting each person we see with a “Good morning” and a smile.
WHAT DOES A SMILE CONVEY?
Our smiles, which convey many of our feelings and thoughts and our sentiments. The parts of a smile such as the lips and its contents that confines them, the teeth, may show how that grin is cared for. The teeth themselves reflect our age; what’s inside one’s heart, whether we are friendly, trustworthy, attentive and warm, especially when greeted with good eye-to-eye contact. In its absence we may hesitate to approach an individual. It’s an important part of a person and a warm bright smile is what helps to make that impression.
Recall this ever-famous rule “You only get one shot to make a good first impression” and adding an appealing smile is essential to do that. One study of 1,047 people from 2012 revealed that people with straight teeth are perceived as more successful smarter and having more dates. 1
THE SMILE EXPERTS
Dentists are the pan-ultimate expert on the smile. It’s our duty to inform patients and the parents or guardian of their dependent children to monitor, maintain and return for recalls. Educating parents on the importance of treating teeth that have delayed eruption and explain that there is a small window of opportunity to bring about normal full eruption and cap off a bright smile. Once individuals leave their teens, the likelihood of assisted eruption decreases, possibly due to root ankylosis. Root formation is the force that causes a tooth to erupt. Once a root has formed it’s potential to erupt decreases. Teeth passively erupt naturally once they have reached the occlusal plane and maintain their position with the opposing forces of the oral soft tissues from the cheek, the tongue and the opposing tooth contact. We see some teeth over erupt when there is no opposing tooth to prevent it from continually erupting. However, a tooth that never erupts may move in its position within the jaw over time. This has been shown to occur. 2
Approximate Synonyms
• Failure of tooth eruption associated with tooth impaction
• Failure of tooth eruption with tooth impaction
• Impacted teeth with abnormal position
• Impacted tooth, malposition
• Impacted tooth, non-supranumerary
• Nonsupranumerary impacted tooth
Clinical Information
• A condition in which a tooth is so crowded in its socket that it cannot erupt normally.
• A tooth that is prevented from erupting by a physical barrier, usually other teeth. Impaction may also result from orientation of the tooth in an other than vertical position in the periodontal structures.3
SURGICAL CASES TO ASSIST IN ACHIEVING A COMPLETE 😊SMILE
CASE REPORTS:
1. 14 y/o healthy girl referred for exposure and bracket placement tooth #11. As you can see it is in good proximity with a fully formed root from the panorex supplied by her general dentist. Tooth #H and #C had been extracted by the general dentist 6 months prior to allow #11 and #6 to erupt, #6 erupted but #11 did not. Clinical exam revealed the crown of the tooth on the palatal aspect which required a full thickness flap to access the crown of#11 and perform a controlled elevation to insure the tooth isn’t ankylosed, and placement of an orthodontic bracket and chain on the palatal aspect. I like to include that in my notation to the orthodontist because the tooth may rotate while it is erupting. When the labial aspect is accessible that is the preferable surface to bond the bracket to the tooth because it erupts the tooth into a more anatomically correct position. Additionally, when a well-defined soft tissue mass is encountered, it is curetted and sent for histopathologic review. Having the tissue evaluated is important because this is what defines and labels it especially since clinicians don’t have “microscopic vision”. We can never say for sure what it is until it is examined under a microscope. After suturing the site, a post-op periapical radiograph shows the tooth with the bonded bracket and attached chain in position and ligated to the arch wire with either ortho wire or a suture. The post-op course was uneventful.
At 18 y/o she returns with an acute pericoronitis, insufficient arch length requiring extraction of her impacted infected wisdom teeth. We see fully erupted and well aligned and positioned teeth with the exception of #1,16,17,32 after full orthodontic treatment. At that time, we extracted all four impacted wisdom teeth with moderate intravenous sedation and the patient tolerated the procedure and healed uneventfully.
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2. This healthy 17 y/o boy referred for exposure of fully impacted #11. Although he is older than the average patient needing a tooth exposed for eruption, his parents and he preferred to try to see if the tooth will erupt when orthodontic forces are applied. It is important to note that the older the patient is, the less likely it is that the tooth will erupt because it may be ankylosed.
Under local anesthesia and nitrous oxide analgesia tooth #11 was confirmed by clinical exam on the palatal aspect which required a full thickness palatal flap and reflection to access the crown of #11 requiring removal of bone around the crown and controlled elevation of the tooth to confirm it isn’t ankylosed and bonding and bracketing of the crown on its palatal aspect. The site was sutured closed and a post-operative periapical taken. The patient did well post-op.
Under local anesthesia and nitrous oxide analgesia tooth #11 was confirmed by clinical exam on the palatal aspect which required a full thickness palatal flap and reflection to access the crown of #11 requiring removal of bone around the crown and controlled elevation of the tooth to confirm it isn’t ankylosed and bonding and bracketing of the crown on its palatal aspect. The site was sutured closed and a post-operative periapical taken. The patient did well post-op.
2 1/2 years later at age 20 he presents with a symptomatic acute recurrent pericoronitis requiring extraction of the malposed and impacted and infected wisdom teeth. All his teeth are well aligned and we can see #11 positioned and functioning within the arch. He opted for moderate sedation for his treatment. All four teeth #1,16,17,32 were extracted. Tooth 17 distal root tip fracture. Attempts to elevate the fragment with small root picks was unsuccessful and the decision was made to leave the fragment positioned just over the IAN (inferior alveolar nerve) canal. All areas were debrided and sutured and the patient did well post op understanding that there was a root fragment which was explained to his parents and him before the treatment and advised about the fragment post-operatively. In addition, we discussed the periapical pathology and treatment associated with #19 mesial roots.
Maxillary canines are more likely not to erupt due to insufficient arch length or ankylosis when compared to mandibular anterior teeth and when it involves the anterior teeth, our “smiling teeth” it is very noticeable. Addressing delayed eruption before the child is a teen is important to maintain the alignment of the teeth, the function of the anterior teeth in incising and chewing food, and it also affects speech and the lingual sounds we make. Waiting too long for nature to do what it is intended may cause the patient to miss out on the important window of opportunity to bring the tooth into the arch. With this in mind it is always best to have a child who is missing a tooth should have it evaluated without delay because of the possibility of it not erupting.
THE GIRLDOC😉
2.https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/white_paper_third_molar_data.pdf
https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/white_paper_third_molar_data.pdf
3. https://www.icd10data.com/ICD10CM/Codes/K00-K95/K00-K14/K01-/K01.1#:~:text=Billable%2FSpecific%20Code-,K01.,a%20diagnosis%20for%20reimbursement%20purposes.
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