Surgical Exposure of a Lower Premolar: comments?

Very simple case, full thickness flap attach bracket and thread chain or wire up under the flap. Tooth will erupt under the flap. May need a ct tissue graft as tooth appears thru the crest.. You can pack some iodoform gauze to hold the flap access but the bracket will prevent the flap from healing over. The trick is making enough room for the tooth to erupt. I would also remove the thirds. Don't try to expose the crown let the tissue develop as the tooth erupts. Not sure what this has to do with implants?

The flap should be apical lay positioned thus the attached gingiva will be apical lay positioned. The gingiva will follow the tooth.

Would using a soft tissue laser to expose the crown be an option here? I understand there may be the need for soft tissue grafting once the tooth is in place. I have done a few exposures (usually for Maxillary canines), but the teeth were not as deep as in this case. Also, I know this doesn't really involve implants - but I love anything oral surgery... Thanks! Justin

CRS is on the money. Having done hundreds of closed "expose and bonds", this technique works perfectly. Keratinized gingiva forms during eruption. No need for CT graft.

I agree with the fact that tissue punch is contraindicated. I would apicaly reposition the tissue as site permits accessing tooth without nerve damage. If tissue is well secures to periosteum under expossed area, there are chances of increasing kertinized tissue as eruption occurs. However, if tissue is not secured to periosteum , you may lose the narrow band of keratinized tissue. The orthodontist needs to creae space for eruuption. It does not look you have enough now. The need for a free gingival graft in the future is likely.

CRS and OMS offer the best treatment solution. Allow the tooth to erupt under the flap. The soft tissue will fall into place. No need to overthink this one.

I preform about 200 of these procedures a year for the last 30 years. I highly recommend splitting the narrow band of attached tissue, expose the crown, do not violate the CEJ, and leave some follicle attached. Bond a gold bracket and chain with elastic thread, and activate every 3-4 weeks. Also it is obvious you need to expand the space and remove the 3rd molar. Attached gingiva and epitheal sulcus will develop as the tooth erupts. Should take about 4-6 months.

If you concerned about mental nerve, you can make wide envelop flap with careful stripping of periostium and no need for vertical incision

Surprised no red flags re 2nd molar !!!!

Thank you all for great comments and guidance

Do you think there is enough to evoke an impacted tooth . While it does not show photographic and X-ray .

Other Red Flags: 1- terrible oral hygiene, generally means bad pt compliance with post-op instructions, and 2- don't do anything to expose the impacted bicuspid until there is room for it...not a lot of sense to expose for eruption that can't take place for another 2-3 months.