The responsibility for the successful execution of this procedure is shared between the oral surgeon and the orthodontist, each complementing the other in applying their very special and different skills to the resolution of the immediate task. Together they possess all the tools that are needed to complete the job, which neither is equipped to do alone.
If bonding an attachment to the tooth is to be carried out a few weeks after the surgery has been performed, then the presence of the orthodontist at the surgeon’s side will be superfluous. However, the reliability of the bonding at this later date will be much poorer [3]. The surgeon will need to expose the tooth much more widely, place surgical packs and aim for healing ‘by secondary intention’. This has been pointed out above and will be explained in greater detail in later chapters.
Table 5.1 Immediate effects of closed and open exposure treatments on quality of life.
| Primary full‐flap closure (closed exposure) |
|---|
| Advantages |
| Rapid healing |
| Less discomfort |
| Good post‐operative haemostasis |
| Less impediment to function |
| Conservative bone removal |
| Immediate traction possible |
| High degree of reliability of bonding possible in close proximity to resorbing root area |
| Disadvantages |
| Presence of orthodontist needed |
| Bond failure dictates re‐exposure |
| Open exposure |
| Advantages |
| Orthodontist’s presence unnecessary |
| Bond failure – needs no surgery |
| Disadvantages |
| Greater risk of infection |
| Greater discomfort |
| Interference with functions of eating, chewing, talking |
| Wider bone exposure |
| Bad taste and smell in mouth |
| Possibility of re‐closure of exposure – dictates re‐exposure |
| Bonding reliability poorer |
| Delayed initiation of traction |
| Poorer periodontal condition |
| Extra visits to change packs |
The team approach to attachment bonding
It is appropriate to note that the development of the team approach to the bonding of an attachment was exemplified in the cooperation, expertise and forbearance of two (now retired) senior oral and maxillofacial surgeons in Jerusalem, Professors Arye Shteyer and Joshua Lustmann. The approach primarily represents an adjunctive surgical procedure, whose aim is to provide a small area of exposed enamel of the impacted tooth for the application of an orthodontic force‐delivery system. Accordingly, it should be carried out on the surgeon’s territory, rather than in the orthodontic clinic.
Before the surgical exposure is attempted, orthodontic treatment will have been initiated and, in most cases, will have reached the stage where levelling and alignment will have been prepared. More substantial steel archwires will have been used during space preparation and a heavier base arch will usually be in place to combine all the teeth into a composite anchor unit.
Those orthodontic procedures that remain to be carried out during the surgical episode are few and relatively simple and can all be performed in the oral surgeon’s operatory. If they are properly prepared in advance, these procedures will not be time‐consuming and will not disturb the surgeon’s patient flow. Practical experience will dictate that the orthodontist should prepare a small tray of instruments and materials that are not normally available in the operating room. In addition, the orthodontist will have prepared an auxiliary device, which will have been chosen or customized at a previous visit, for the purpose of applying a directional force to the impacted tooth. This may take the form of a prepared and individualized ballista spring, or a flexible palatal arch or an auxiliary labial arch (see Chapter 7). The instrument tray should contain the items listed in Table 5.2.
In the treatment of an impacted palatal canine or of almost any other impacted tooth and immediately prior to the surgical exposure, it has been the author’s practice to tie the labial auxiliary arch or other auxiliary into the orthodontic brackets. In its passive mode, the active loop will stand well away from the immediate surgical field and will not interfere with the work of the surgeon. As a poorer alternative, these auxiliaries may be placed on the instrument tray, in readiness for placement at the end of the surgical procedure.
Table 5.2 An instrument tray for a team approach.
| Instruments |
|---|
| Fine wire bending plier (e.g. Begg plier) |
| Fine wire cutter |
| Reverse‐action bracket‐holding tweezers, which are closed when not held and release when handles lightly squeezed |
| Ligature director |
| Mosquito or Matthieu forceps |
| Fine scaler |
| Materials |
| Etching gel |
| Composite bonding material, preferably a light‐curing material |
| Applicators (sponge buds, fine brushes, etc.) |
| Attachments |
| Eyelets welded to thin band material, backed with stainless steel mesh; these should be cut and trimmed into patches of various sizes, but no larger than the base of a small bracket |
| Cut lengths of dead soft stainless steel ligature wire of gauge 0.012 in. or 0.014 in. |
| Elastic thread and elastic chain |
In the first stage of the treatment, the surgeon reflects the palatal soft tissue flap over the impacted tooth and removes the intervening bone, which is usually very thin and easy to peel with a scalpel blade. If a supernumerary tooth or odontome is present, this will be removed first. The dental follicle is then cut open in the target area, immediately overlying the crown, and the resultant exposure is widened. The increase of the width of the exposure should not be more than is necessary to satisfy two basic requirements: (a) to provide enough enamel surface to accept a small attachment; and (b) to do so in an area wide enough for adequate haemostasis to enable the bonding procedure to take place, without fear of contamination.
