For the patient who has had an open exposure procedure, the reliability of bonding at a subsequent visit is, paradoxically, much poorer than when the attachment bonding is performed at the time of surgery for the following reasons. During a closed surgery procedure, a wide tissue flap is usually raised, which provides good visibility and access, especially to a deeply buried tooth. The margins of the wide flap are distant from the tooth, enabling better control of moisture and bleeding in the immediate area. The orthodontist can bond the attachment efficiently, while the surgeon and the nurse maintain haemostasis and the necessary dry field. In contrast, an open exposure involves raising a small flap in the area immediately surrounding the tooth and maintaining the patency of the opening (usually with the help of a periodontal pack) until an attachment is bonded at a later date. At that visit to the Orthodontist Baton Rouge, secondary healing will have occurred, and the newly epithelialized cut surface will be very sensitive to any form of manipulation.
Accordingly, the patient will have avoided brushing the area and a degree of inflammation will be present, due to the accumulation of plaque and the freshness of the healing wound. Prophying the tooth under these conditions of restricted access and fragile hemorrhagic tissue is not conducive to successful bonding. In addition, the presence of eugenol from the periodontal pack may inhibit composite polymerization and thereby weaken the bond strength. When orthodontic brackets are bonded in day-to-day practice, the teeth are first cleaned, using a rubber cup and pumice. The aim of this procedure is to remove extraneous materials, which include soft plaque, dried saliva, organic and chemical staining, and deposits which adhere or adsorb to the enamel prisms and which may prevent penetration of the etchant. Once these are removed, the enamel surface becomes vulnerable to the orthophosphoric acid liquid or gel, which is the key to a successful adhesion of the attachment.
In contrast, newly exposed impacted teeth are completely free of these extraneous materials. Their only covering is Nasmyth's membrane, which is made up of the enamel cuticle and the reduced enamel epithelium and is about 1 micron thick. This appears to present no barrier whatsoever to the etching effect that is achieved by the application of orthophosphoric acid. Accordingly, there is no advantage to be gained by pumicing these teeth as part of the bonding procedure. Rather, the reverse is the case. To permit the introduction of a hand piece and rubber cup or a small electric toothbrush or hand brush, exposure has to be considerably broader for prophylaxis to be effective. It is difficult to control these implements during the brushing exercise and, as a direct consequence, the brush or cup traumatizes the exposed bone and soft tissues. This generates renewed bleeding, while giving rise to a dispersal of the pumice over the immediate surgical held. Prophylaxis is therefore completely superfluous. The successful of the surgery depends on the Orthodontist Baton Rouge and his or her skills.
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Orthodontist Baton Rouge- The Reliability of Bonding