Exodontia.Info
Exposing & Bonding of Brackets to
Teeth
Explanation & Warnings
The objective of exposing ± bonding a bracket on to
an unerupted tooth is to move the tooth into a good
functional & aesthetic position.

Exposure of a tooth at its simplest, consists of removing the
gum overlying the crown of the unerupted tooth under
Local
Anæsthetic
.  Most unerupted teeth are deeper within the
jaw and require the removal of bone as well as the gum to
expose and disimpact them; as a consequence, this may be
done under
General Anæsthetic.

The application of
traction (using the chains attached to
braces) to stimulate and guide the eruption of buried teeth
is necessary as the teeth are unfavourably angled (and
spontaneous eruption is inhibited), where buried teeth are
obstructed from eruption by other teeth & where teeth are
exposed long after their root development is complete.  An
example of an exposed tooth being dragged into its correct
position is shown
here.

Teeth most likely to be exposed and bonded are the upper
canines / eye teeth, upper central incisors, molars and the
occasional
premolars.
Picture of a Gold Chain & Bracket
This list of warnings might seem excessive to some however the legal ruling in
the case of
Chester vs Afshar (2004) would suggest that it is quite prudent /
necessary to list them.  Others might say that there isn't enough information but
where do you stop?

The following list of warnings regarding tooth exposure & bonding is neither
exhaustive nor is it predictive.  The most pertinent warnings have been included
here.

You are to have a
tooth exposed ± bracketed.  You can expect the following:

Exposing ± Bracketing of Tooth Specific Warnings:

Stitches.  The extraction site will often be closed with stitches.  These are
dissolvable and ‘fall out’ within 10 – 14 days.  If a pack has been sewn in or the
chain is ‘parked’ high up in the sulcus, non-dissolving stitches are used, that will
need to be removed at some point.

Brackets.  These are small golden plaques with chains attached.  These are stuck
onto the teeth that need to be moved.  Sometimes, the cement sticking the chain
onto the tooth can break after
traction is applied to the tooth; if this happens, the
bracket will need to be re-cemented on.  Occasionally, the chain itself breaks and
this will mean that the chain and bracket have to be replaced.

Gauze Pack.  Sometimes, it is not possible to stick the chains onto the teeth.  If
this is the case, a gauze pack impregnated with an antiseptic (
BIPP) is placed
over the exposed tooth and sewn into place.  The pack is removed after
approximately a week and the chain will be stuck on at this point.

Ankylosis of Tooth.  Occasionally, even if the tooth has traction applied to it, it still
refuses to move.  If this happens, it is sometimes necessary to explore the area –
there may be a lip of bone preventing the tooth from moving or the tooth has fused
with the surrounding bone (
ankylosis).

Repeated Operation.  The gum can easily grow back over the exposed tooth.  If
this is the case and the tooth doesn’t have a bracket stuck on it, the tooth will need
to be re-exposed, hence another operation.


General Surgical Warnings:

Pain.  As it is a surgical procedure, there will be soreness after the procedure.  
This can last for several days.  Painkillers such as
ibuprofen, paracetamol,
Solpadeine or Nurofen Plus are very effective.  Obviously, the painkiller you use is
dependent on your medical history & the ease with which the tooth was exposed.

Swelling.  There will be swelling afterwards.  This can last up to a week.  Use of
an icepack or a bag of frozen peas pressed against the cheek adjacent to the
tooth removed will help to decrease the swelling.  Avoidance in the first few hours
post-op, of alcohol, exercise or hot foods / drinks will decrease the degree of
swelling that may develop.

Bruising.  Some people are prone to bruise.  The bruising can look quite florid; this
will resolve but can take several weeks (in the worst cases).

Limited Mouth Opening.  Often, the chewing muscles and the jaw joints are sore
after the procedure so that mouth opening can be limited for the next few days.


Useful Articles:

British J Orthodontics 1998.  The Ectopic Maxillary Canine - A Review

Dental Update 1999.  The Apically Repositioned Flap in Tooth Exposure

Dental Update 2000.  Modified Apically Repositioned Flap in the Treatment of
Unerupted Maxillary Central Incisors

American J Orthodontics & DentoFacial Orthopedics 2004.  Surgical & Orthodontic
Management of Impacted Maxillary Canines

Cochrane Review 2008.  Open versus closed surgical exposure of canine teeth
that are displaced in the roof of the mouth

BJOMS 2010.  Exposure of unerupted palatal canines. A survey of current
practice in the UK & experience of a gingival-sparing procedure

RCS England Guidelines 2010.  Management of the palatally ectopic maxillary
canine

Braz J Oral Sci 2010.  Palatally Impacted Canine.  Diagnosis & Treatment Options

European J Orthodontics 2011.  A Systemic Review of the Interceptive Treatment
of Palatally Displaced Maxillary Canines

Oral Surgery 2011.  Case Report.  The Trouble with Ectopic Maxillary Canines – A
Cautionary Tale of 2 Cases

BDJ 2012.  National Clinical Guidelines for Management of the Palatally Ectopic
Maxillary Canine

Evidence-Based Dentistry 2012.  Need for further clarity on optimal approach to
ectopic canines

J Pharmacy & Bioallied Sciences 2012.  Impacted Canines: Etiology, diagnosis,
and orthodontic management

Dent Update 2013. Guidelines for the Assessment of the Impacted Maxillary
Canine

Progress in Orthodontics 2013.  An easy method of attachment to an impacted
canine



Information Sheets from NHS Hospitals regarding Impacted Canines & Their
Exposing & Bonding
:

Ashford & St Peter's Hospitals NHS Foundation Trust.  Removal of Impacted
Canines

North Bristol NHS Trust.  Impacted Canines

Oxford Radcliffe Hospitals NHS Foundation Trust. Surgical to Expose Buried
Canine Teeth

South Devon Healthcare NHS Foundation Trust. Surgical Exposure of Impacted
Canine Teeth
Photos, from the front and side, of an Upper Left Canine
Tooth that has had a Bracket & Chain attached to it
Last Updated 22nd January 2016