during the first couple of post‐surgical months. Such manipulation is unpleasant and even painful for the patient as the pigtail passes through the soft tissues.
There is much to be said for the first adjustment being fully exploited, with the application of appropriate traction while a local anaesthetic is still operational, i.e. at the time of surgical exposure. Subsequent manipulation may then only be necessary for two or three additional adjustment visits, before the tooth is erupted and before the pigtail becomes free from the soft tissue. If, prior to the surgery, an auxiliary labial archwire or a ‘ballista’ spring in its passive mode has been tied into the arch, as already recommended, then lightly pushing the loop from its vertical, inactive position towards the mid‐palate and turning the pigtail ligature around it will provide appropriate light and continuous extrusive force. This will be active over a wide range of movement and will remain active for many weeks. Similarly, an auxiliary palatal arch may be slotted into the palatal horizontal molar tubes then raised, to be held by the pigtail ligature. Whichever of these devices is used, this orthodontic manoeuvre should take no more than a minute or two and can be done while the surgical instruments are being cleared away.
With the procedure described, and attachment placement performed by the orthodontist and with moisture control under the care of the surgeon, the bonding has been shown to be very reliable [3]. However, this has not always been the prevailing opinion. In the past, bonding in the presence of an open and bleeding wound, involving both soft and hard tissues, was strenuously resisted, since it was thought to be inconsistent with the attainment of a dry and uncontaminated field. This mistaken opinion on the part of the orthodontist was probably born more out of a reluctance to be present at the surgical episode than out of any experience of a high incidence of failure in attachment bonding in these circumstances.
From the discussion here, it will be abundantly clear that the presence of the orthodontist at the surgical intervention has multiple positive aspects:
The orthodontist is able to see the exact position of the crown, the direction of the long axis and the deduced location of the root apex.
The height of the tooth and its relation to adjacent roots may be noted and the orthodontist will be able to confirm the strategic plan for its resolution by direct visualization.
The orthodontist will be in a position to decide, from the mechano‐therapeutic aspect, exactly where he or she would like to see the attachment placed and will bond it there.
The orthodontist is also the best person to fabricate, place and activate a suitable and efficient auxiliary to apply a directional force of optimal magnitude and range of movement and to do so at the time of actual surgery.
It is not fair to expect oral surgeons to be aware of how the different attachment locations may affect the orthodontic or periodontic prognosis; nor should they be expected to be sufficiently experienced with the bonding technique to do it themselves. Bonding is not a procedure that oral surgeons routinely carry out. The presence of the orthodontist allows for bonding to be performed efficiently, while the surgeon and the nursing attendant maintain haemostasis and the necessary dry field.
Some surgeons may take exception to the presence of the orthodontist at the exposure and may even use expressions like ‘even the lowliest oral surgeon can place a bracket’ or that it is ‘a waste of time’ [52]. It will then be quite apparent that the oral surgeon had sorely missed the point and had not understood the wider context of ensuring quality care and overall treatment success.
The ultimate responsibility for the success of the case rests firmly on the shoulders of the orthodontist, from the initiation of orthodontic treatment up to the point where the impacted tooth is brought into full alignment and, almost invariably, until the overall malocclusion is resolved. It would be irresponsible to abrogate the management of this crucial stage of the treatment to another party, when there is force to be applied to the newly exposed impacted tooth and where so much is at stake that will affect the future of the case. If, as has been advocated by many orthodontists and surgeons alike, orthodontists absent themselves and leave surgeons to make orthodontic decisions for which they are not equipped, they will be endangering the outcome and inviting legal proceedings, from which the orthodontist involved will not be immune.
References
1 1. Becker A, Zilberman Y. A combined fixed‐removable approach to the treatment of impacted maxillary canines. J Clin Orthod 1975; 9: 162–169.
2 2. Becker A, Zilberman Y. The palatally impacted canine: a new approach to its treatment. Am J Orthodont 1978; 74: 422–429.
3 3. Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. Eur J Orthod 1996; 18: 457–463.
4 4. Becker A, Chaushu S, Casap‐Caspi N. CBCT and the orthosurgical management of impacted teeth. J Am Dent Assoc 2010; 141 (10 suppl): 14S–18S.
5 5. Becker A, Chaushu S. Surgical treatment of impacted canines: what the orthodontist would like the surgeon to know. Oral Maxillofac Surg Clin North Am 2015; 27: 449–458.
6 6. Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am 1993; 37: 181–204.
7 7. Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop 2004; 126: 278–283.
8 8. Becker A, Kohavi D, Zilberman Y. Periodontal status following the alignment of palatally impacted canine teeth. Am J Orthod 1983; 84: 332–336.
9 9. Kohavi D, Becker A, Zilberman Y. Surgical exposure, orthodontic movement and final tooth position as factors in periodontal breakdown of treated palatally impacted canines. Am J Orthod 1984; 85: 72–77.
10 10. Kohavi D, Zilberman Y, Becker A. Periodontal status following the alignment of buccally ectopic maxillary canine teeth. Am J Orthod 1984; 85: 78–82.
11 11. Boyd R. Clinical assessment of injuries in orthodontic movement of impacted teeth. I. Methods of attachment. Am J Orthod 1982; 82: 478–486.
12 12. Boyd R. Clinical assessment of injuries in orthodontic movement of impacted teeth. II. Surgical recommendations. Am J Orthod 1984; 86: 407–418.
13 13. Wong‐Lee TK, Wong FCK. Maintaining an ideal tooth–gingiva relationship when exposing and aligning an impacted tooth. Br J Orthod 1985; 12: 189–192.
14 14. Korbendau J‐M, Guyomard F. Chirurgie parodontale orthodontique. Velizy‐Villacoublay: Editions CdP, 1998.
15 15. Kokich VG. Preorthodontic uncovering and autonomous eruption of palatally impacted maxillary canines. Semin Orthod 2010; 16: 205–211.
16 16. Kupietzky A. Correction of ectopic eruption of permanent molars utilizing the brass wire technique. Pediatr Dent 2000; 22: 408–412.
17 17. Ilizarov G, Devyatov A, Kamerin V. Plastic reconstruction of longitudinal bone defects by means of compression and subsequent distraction. Acta Chir Plast 1980; 22: 32–46.
18 18. Altuna G, Walker DA, Freeman E. Rapid orthopedic lengthening of the mandible in primates by sagittal split osteotomy and distraction osteogenesis: a pilot study. Int J Adult Orthod Orthognath Surg 1995; 10: 59–64.
19 19. Becker A, Zogakis I, Luchian I, Chaushu S. Surgical exposure of impacted canines: open or closed surgery? Semin Orthod 2016; 22: 27–33.
20 20. Chaushu S, Brin I, Ben‐Bassat Y, Zilberman Y, Becker A. Periodontal status following
