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10.5005/jp-journals-10021-1072
CLINICAL INNOVATION
B Nazeer Ahmed Meeran
An Efficient Technique of Bonding Orthodontic
Attachments to Surgically Exposed
Impacted Teeth
B Nazeer Ahmed Meeran
ABSTRACT
Bonding orthodontic attachments to surgically exposed impacted teeth have always been a challenge in terms of predictability of the
bonded attachment, mainly due to the blood contamination at the surgical site. The present article describes a simple technique of achieving
hemostasis at the surgical site and ensuring an uncontaminated and dry field, favorable for acid etching, sealant application and bonding
with light curable composite.
Keywords: Impactions, Hemostasis, Bonding to impacted teeth.
How to cite this article: Meeran BNA. An Efficient Technique of Bonding Orthodontic Attachments to Surgically Exposed Impacted Teeth.
J Ind Orthod Soc 2012;46(2):116-118.
INTRODUCTION
Surgical exposure of an impacted tooth is necessary to allow
the orthodontist access to the unerupted tooth, in order to bring
it into the dental arch and into alignment. However, blood
contamination during bonding can lead to premature failure of
the bond.1 Even momentary saliva or blood contamination
adversely affects the bond. This is because saliva and blood
deposit an organic adhesive coating within the first few seconds
of exposure which is resistant to washing.2
The placement of an orthodontic attachment on the tooth
may be performed at the time of surgery or at a later date.
Delaying the bonding procedure until healing has occurred
results in little risk of contamination with blood or moisture.
However, the soft tissues that cover the exposed tooth have to
be excised or repositioned to expose the crown of the tooth.
This can result in a poor gingival margin3 and is not desirable,
particularly in situations in which nonkeratinized, unattached
gingiva or mucosa would have to be removed to achieve the
exposure.
Enamel surface contamination can occur at two critical times
of the bonding procedure: After the tooth surface has been
etched and after the primer has been applied. Bonding could be
compromised at both of these times. In a blood contaminated
environment, self etching primers and moisture insensitive
primers are not very efficient and studies have shown that blood
contamination significantly reduced the shear bond strength of
brackets bonded with conventional primers and self etching
primers.4 It has also been proved that blood contamination on
acid-etched surfaces affects bond strength more than saliva
contamination.5 Thus, it would be advantageous to be able to
bond to enamel in a hemostatic environment, particularly on
surgically exposed impacted teeth, for immediate bonding of
orthodontic attachments.
Expasyl* is a paste used for gingival retraction that opens
the sulcus, physically displacing the tissue and leaving the field
dry, ready for impression taking or cementation (Figs 1A and
B). It contains 15% aluminium chloride, kaolin and water. The
aluminium chloride present in the paste provides excellent
hemostasis and seepage control which can be taken advantage
of, while bonding orthodontic attachments to surgically exposed
impacted teeth. The mechanism of action of aluminium chloride
is mainly due to its ability to precipitate tissue and blood
proteins, causing a mechanical obstruction to hemorrhage from
injured blood vessels. It also has the capability to extract fluid
from the tissues. Aluminum chloride is highly soluble in water,
freely soluble in alcohol and soluble in glycerin. Aluminum
chloride has no contraindications and minimal side effects.6
Assistant Professor
PROCEDURES
Department of Orthodontics and Dentofacial Orthopedics
Priyadarshini Dental College and Hospital, Pandur, Tamil Nadu, India
A 15-year-old female patient had a buccally impacted maxillary
canine, which was in a favorable position to be brought into the
arch and alignment. The retained deciduous canine was
extracted to create space for the impacted canine (Fig. 2A) and
Corresponding Author: B Nazeer Ahmed Meeran, Assistant
Professor, Department of Orthodontics, Old No 6, New No 11, NGO
Colony, First Street, Nanganallur, Kendriya Vidyalaya School Road
Chennai-600 114, Tamil Nadu, India, e-mail: [email protected]
*ExpasylTM, Kerr Expasyl—gingival retraction paste, Kerr corporation,
Produits Dentaires Pierre Rolland, Merignac Cedex, France
Received on: 6/3/11
Accepted after Revision: 19/8/11
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Note: The authors do not have any financial interest in the product
mentioned in the above article.
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JIOS
An Efficient Technique of Bonding Orthodontic Attachments to Surgically Exposed Impacted Teeth
Figs 1A and B: (A) Expasyl with gun and capsule (cartridge) assembly, (B) Expasyl gingival retraction paste in capsule
Figs 2A to I: Site after extraction of retained deciduous canine, (B) Bleeding seen immediately on raising a buccal flap, (C) Expasyl paste
placed in the surgical site for hemostasis, (D) Bleeding controlled with better visibility of the surgically exposed tooth, (E) Attachment bonded
and subjected to light curing, (F) Ligature wire engaged to the attachment, (G) Ligature wire attached to the main archwire, (H) Flap sutured
back into place, (I) Three months after surgical exposure
a flap was raised buccally to gain access to the impacted canine
(Fig. 2B). Immediately after surgical exposure of impacted teeth,
the Expasyl paste is placed over the surgical site for 2 minutes
and is then flushed away with water spray and suction (Fig. 2C).
The surgical site is then air dried. This ensures a dry and
bloodless field, conductive to bonding orthodontic attachments
to the surgically exposed teeth (Fig. 2D). The attachment is
bonded with Transbond XT composite** after acid etching with
37% phosphoric acid gel for 30 seconds, followed by thorough
washing and drying. A thin layer of Transbond XT primer is
applied on the etched enamel and the attachments are bonded
to the surgically exposed tooth, following the regular protocols
and subjected to light curing for 40 seconds (Fig. 2E). A self
ligating bracket was bonded to the impacted canine and a
The Journal of Indian Orthodontic Society, April-June 2012;46(2):116-118
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B Nazeer Ahmed Meeran
ligature wire was threaded through the bracket slot (Fig. 2F).
The ligature wire was then tied and attached to the main
archwire, in order to give mild eruptive force and guide the
impacted tooth into the arch (Fig. 2G). The flap was then sutured
back into place (Fig. 2H). The patient did not report any
discomfort after the surgical procedure and there was no
incidence of bond failure during the next 3 months (Fig. 2I),
until the bracket was debonded by the operator to reposition it
at the ideal crown level.
DISCUSSION
Hemostatic agents ensure an uncontaminated and dry field;
favorable for acid etching, sealant application and bonding with
light curable composite, thus reducing the risk of bond failure.
A variety of local hemostats, including absorbable gelatin
sponge, collagen hemostat and oxidized cellulose, are
commercially available. However, these are not ideal for
orthodontic purpose. Calcium sulphate hemihydrates (Plaster
of Paris), has been recently used for hemostasis to attach
orthodontic attachments to surgically exposed impacted teeth
with good results.7 However, it must be acknowledged that
manipulation of plaster of Paris is a messy work, particularly
considering the sterile environment of the surgical office and
the time taken for the plaster to set and the effort required to
remove it completely form the surgical site after achieving
hemostasis.
The gingival retraction cord is currently being used for
gingival retraction while taking impressions for crowns and
bridges. In addition, they also serve as effective hemostatic
agents, controlling gingival bleeding and providing efficient
seepage control. Gingival retraction cords containing
epinephrine effectively control bleeding; however, 24 to
92% of epinephrine may be absorbed systemically. Astringents
impregnated in retraction cords include aluminum chloride, ferric
sulfate, alum (potassium aluminum sulfate) and zinc chloride.
Alum and ferric sulfate may be irritating and even corrosive at
high concentrations, while increased concentrations of zinc
chloride may damage bone and tissue permanently.
The least irritating cords contain buffered aluminum
chloride, which may be left in contact with the gingival tissue
for up to 15 minutes without permanent damage.8 Histological
studies have proved that it does not cause any adverse effects
on the gingival and periodontal tissues and exhibits excellent
biocompatibility.9 Hemostatic agents ensure an easy and
efficient way of bonding orthodontic attachments to impacted
teeth immediately after surgical exposure and will go a long way
in helping orthodontists bond better in a bloody field, minimizing
the risk of bond failure. The bonded attachments can be
immediately subjected to orthodontic forces without any risk
of premature failure of the bond.
REFERENCES
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964-68.
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**TransbondTM XT-3M Unitek Monrovia, CA.
Note: The authors do not have any financial interest in the product
mentioned in the above article.
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