Expose & Bond

Preoperative Considerations

Consent:

Devitalization of adjacent teeth

Anesthesia/Positioning:

Other:

Imaging: CBCT, to plan access (buccal or lingual/palatal) accordingly
Ensure patient has follow up planned with their orthodontist

Armamentarium:

1-2% Lidocaine w/ 1:100,000 epi , syringe and 27 gauge needle
Minnesota
15 blade
#9 periosteal elevator
Electric drill with round carbide bur
Irrigation
Dental curette
Dry angles, cotton rolls, 4x4 gauze
ViscoStat 20% Ferric Sulfate or similar hemostatic agent
Gold button and chain
Dental etchant
Bonding adhesive
Ortho cement
Cure light
4-0 silk
3-0 chromic gut suture
Needle holder
Pickups
Scissors

Technique

Inject lidocaine (nasopalatine and greater palatine nerve blocks for palatal impaction)
Sulcular incision with 15 blade
Using #9 reflect full thickness mucoperiosteal flap
Remove bone overlying crown of impacted tooth. DO NOT remove bone all the way to CEJ
Confirm mobility of impacted tooth, if no mobility gently luxate
Apply viscostat, wait 2 minutes, then rinse with saline
Etch enamel (30 seconds), rinse with saline, dry
Obtain isolation with gauze, dry angles
Bond and cure
Cement gold button and chain, cure 2 cycles. Gently pull on gold chain to ensure adequate bonding
Pass 4-0 silk through end of gold chain and tie to ortho wire
Thoroughly irrigate under flap
Closure of flap with 3-0 chromic

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Postoperative Considerations

Immediate:

Soft Diet
Postop antibiotics not indicated

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Follow Up:

FU with orthodontist

Operative Note

Surgeon(s): ***

‍Assistant Surgeon(s): ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts: Correct x2

‍Indications: ***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail. The patient was transferred to the operating room by the anesthesia team. The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures. A time-out was performed and the procedure began.

2% lidocaine with 1:100,000 epinephrine delivered via GPNB, NPNB, and infiltration. 15 blade used to make sulcular incision from second premolar to second premolar. Full thickness mucoperiosteal flap raised on palate with perioseal elevator. Bone removed with surgical handpiece overlying the crown of impacted tooth. Mobility confirmed with elevator. ViscoStat 20% Ferric Sulfate applied for 2 minutes. Rinsed with saline. Dental etchant applied to enamel of impacted tooth. Rinsed with saline after 30 seconds. Isolation achieved with 4x4 gauze. Bonding agent applied to crown of impacted tooth and cured. Gold button and chain cemented and applied to crown of impacted tooth. Cured x2 cycles. Gold chain gently pulled to confirm adequate bond. Chain affixed to ortho wire with 4-0 silk. Copious irrigation under flap. Closure with 3-0 chromic in interrupted fashion. Hemostasis was achieved.

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

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Coding

D7280 surgical access of an unerupted tooth An incision is made and the tissue is reflected and bone removed as necessary to expose the crown of an impacted tooth not intended to be extracted.
D7282 mobilization of erupted or malpositioned tooth to aid eruption To move/luxate teeth to eliminate ankyolosis; not in conjunction with an extraction.
D7283 placement of device to facilitate eruption of impacted tooth Placement of an orthodontic bracket, band or other device on an unerupted tooth, after its exposure, to aid in its eruption. Report the surgical exposure separately using D7280.