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Application of enamel adhesives in oral surgery
Int. J. Oral Surg. 1974: 3 : 2 2 3 - 2 2 6 (Key words: enamel adhesives; sttrgeiT, oral)
Application of enamel adhesives in oral surgery BEJAN IRANPOUR
The Genese Hospital, Eastman Dental Cente15 Rochester, New York, U.S.A.
ABSTRACT Intermaxillary fixation with enamel adhesives was established in several patients, The adhesives were used to attach a metal hook to the tooth surfaces and, in some cases, hooks were developed from the adhesive material. It appears from this preliminary experience that the adhesives can be successfully used for intermaxillal3r stabilization in certain cases. The advantages and disadvantages of the technique are discussed. - -
In recent years, tissue adhesives have been used successfnlly for dental caries prevention and dental restorations 1-8. The reaction product of bisphenol A and glycidyl methacrylate, activated by benzoin methyl ether catalyst (Nuva-Seal| is a dependable enamel adhesive. The Nuva-Seal, when polymerized with ultraviolet light on an acid etched enamel surface, forms a strong mechanical bond by extending projections into the myriads of microspaces between the enamel prisms created by acid etching1. The adhesive is nondamaging to the pulp tissue when applied only to the enamel surface.
Material and methods Prior to clinical application of the adhesives, Erich arch bars and individual metal hooks were attached to the enamel surfaces of human
teeth with the enamel adhesives (Nuva-Seal| and Nuva-Fil| instead of the conventional circumdental wiring. Retention was obtained by notching the metal bar and the hooks, since the adhesive does not bind to metal. The technique of application was essentially similar to that used for fissure sealing and restorative procedures. Following conditioning of the enamel surface for 1 rain with 50 % phosphoric acid containing 7 % dissolved zinc oxide by weight, the surface was rinsed with water and dried. A thin layer of Nuva-Seal was applied and polymerized with ultraviolet light. Then a 2 mm thick layer of Nuva-Fil was applied on the surface and polymerized following immersion of the metal bar or hook into it. One kilogram of weight was suspended from the hooks for 8 weeks under a constant stream of water. No separation of the adhesive or the hooks from enamel surfaces was obse~wed at the end of the eighth week. Since this laboratory observation suggested adequate bonding strength of the adhesives to tolerate long-term traction, the procedure was used in the following clinical trial.
224
'~':
IRANPOUR
:.5:
,.
9 ]:
'
2.: ~
Y.2:
Fig. 1. Erich arch bar hooks are attached to tooth surfaces with Nuva-Fil.
Clinical trial Mandibular fractures, requiring intermaxillary immobilization for closed reduction, were selected for application o.f the adhesives. A t first, individual metal hooks cut from the Erich arch bar were placed on the tooth surfaces wi~h Nuva-27il (Fig. 1). Later it was found that Nuva-F[l hooks could be easily and directly hand formed oa each tooth surface and provided as much stability as the metal hooks (Fig. 2). The N u v a - F i l hook technique is simple a n d usually requires ao local or general anesthetics. Following conditioning of enamel, a thin layer of Nuva-Seal is applied and polymerized for 1 rain by exposure to ultraviolet light. Nuva-FiI is then shaped to a desired hook form directly on the tooth sur-
race and poIymerized for 1.5 to 2 rain, This procedure is repeated on all the teeth to be used for intermaxillary fixation. No waiting period is required for application of traction after the N uva-Fil hooks are polymerized. Fig. 3 shows a fracture of the right angle of the mandible which was immobilized with multiple metal hooks attached to the tooth surfaces with Nuva-Fil (Fig. 4). One of the hooks (maxillary left canine) was formed from Nuva-Fil. During 5 weeks of immobilization, with elastics on the hooks, the occlusion remained satisfactory and stable. Ot~e molar hook became detached and was rebonded without difficulty.
Fig. 3. Fracture of right angle of mandible (arrow) which was immobilized with Nuva-Fil and metal hooks technique.
~: ~ ~il ~ ~
Fig. 2. Shows Nuva-Fil hooks directly formed and t~olymerized on the teeth. A wide base and thick hook structure are formed to minimize breakage.
>:i
~:..
:
~~ (
~'~?~;?~i~!....
Fig. 4. Immobilization of fracture shown in Fig. 3, with elastics applied to metal hooks.
ADHESIVES IN ORAL SURGERY
[
225
/
Figs. 5 and 6. Fractures of right angle (arrow) and symphysis of mandible (arrow) are shown. The panorex was taken after extraction of third molar in line of fracture and just prior to immobilization. These fractures were reduced by intermaxillary fixation, using adhesives (Fig. 7).
Fig. 7. Closed reduction of fractures shown in Figs. 5 and 6 with multiple Nuva-Fil hooks and wires. A strip of Nuva-Fil is placed on mandibular anterior teeth and across symphysis fracture (arrow) for further support.
Fig. 8. The patient shown in Fig. 7, immediately following removal of Nuva-Ffl hooks and polishing of tooth surfaces. Note absence of gingival inflammatory response usually produced by conventional arch bars.
Figs. 5 and 6 are radiographs of the fractures of the right angle and symphysis of the mandible o,f a 19-year-old Caucasian male. These fractures were treated with closed reduction technique, using multiple Nuva-Fil hooks. After establishing a normal occlusM relationship, a 3 mm thick N u v a - F i l strip was formed and polymerized on the mandibular anterior teeth across the symphysis fracture to provide further support (Fig. 7). Fig. 8 shows the same case after 7 weeks of immobilization and immediately following rernoval of the adhesive hooks and strip. There is a notable absence of the gingival inflammation and enlargement usually seen with conventional arch bars. After 6 months the healing and alignment of the fractures are most satisfactory. The adhesives were also used for treatment of alveol~u- fractures and mobile and evulsed teeth. Fig. 9 shows a maxillary lateral incisor which was mobile following trauma and stabilized with a Nuva-Fil strip.
Discussion In our experience, the enamel adhesives,
226
IRANPOUR
Fig. 9. A mobile maxillary right lateral incisor,
stabilized with a Nuva-Fil strip.
when applied properly, provide sufficient strength for intermaxillary immobilization and traction. There are distinct advantages as well as certain limitatio.ns and disadvantages in the applicatio.n of the adhesives for management of some of the traumatic injuries. The major advantages of the technique, compared to the conventional metal arch bars, are lack of pain and discomfo,rt for the patient during application and no injury to the gingival tissues and the periodontium. Application o,f the adhesives, in our experience, requires no m o r e time than the other conventional methods. Simplicity of the technique of application, reasonable cost and patient's acceptance are among the other advantages. The major limitation for application of the adhesives in oral surgery is the necessity for absolute dryness, a requirement which cannot always be met in cases of oral and facial trauma. A disadvantage experienced in some of our cases was the breakage of a few hooks, but they were easily replaced. T h e breakage was most likely related to im-
proper placement technique and thin hooks. Careful placement technique, :faster polymerizing adhesives and thicker hooks will minimize the incidence of breakage. At the end of the immobilization period, the Nuva-Fil hooks and strips are easily cut off with a fissure burr, without need for anesthesia, and the tooth surfaces are restored to a high polish with sandpaper discs and a rubber wheel. This procedure can be performed by auxiliary personnel and requires little time. Further improvernent in the speed of polymerization and development of prefabricated resin hooks and bars will increase the applicability of the adhesives in management of traumatic injuries of the teeth and jaws.
References 1. BUONOCOI~.E,M. G.: Bonding to hard dental tissues. Adhesion in biological systems. Academic Press, New York 1970, p. 225-254. 2. BUONOC0RE, M. G.: Adhesives for pit and fissure caries control. Dent. Clin. Norlh Am. 1972: 16: No. 4. 3. WARD, C. T., BUO•OCORE, M. G. & WOOLRIDGE, E. D. JR.: Preliminary report of a technique using Nuva-Seal in the treatment and repair of anterior fractures without pins. N.Y. State Dent. J. 1972: 38: 269-274.
Address: Department of Dentistry The Genesee Hospital 224 Alexander St. Rochester, New York 14607 U.S.A.
Application of enamel adhesives in oral surgery BEJAN IRANPOUR
The Genese Hospital, Eastman Dental Cente15 Rochester, New York, U.S.A.
ABSTRACT Intermaxillary fixation with enamel adhesives was established in several patients, The adhesives were used to attach a metal hook to the tooth surfaces and, in some cases, hooks were developed from the adhesive material. It appears from this preliminary experience that the adhesives can be successfully used for intermaxillal3r stabilization in certain cases. The advantages and disadvantages of the technique are discussed. - -
In recent years, tissue adhesives have been used successfnlly for dental caries prevention and dental restorations 1-8. The reaction product of bisphenol A and glycidyl methacrylate, activated by benzoin methyl ether catalyst (Nuva-Seal| is a dependable enamel adhesive. The Nuva-Seal, when polymerized with ultraviolet light on an acid etched enamel surface, forms a strong mechanical bond by extending projections into the myriads of microspaces between the enamel prisms created by acid etching1. The adhesive is nondamaging to the pulp tissue when applied only to the enamel surface.
Material and methods Prior to clinical application of the adhesives, Erich arch bars and individual metal hooks were attached to the enamel surfaces of human
teeth with the enamel adhesives (Nuva-Seal| and Nuva-Fil| instead of the conventional circumdental wiring. Retention was obtained by notching the metal bar and the hooks, since the adhesive does not bind to metal. The technique of application was essentially similar to that used for fissure sealing and restorative procedures. Following conditioning of the enamel surface for 1 rain with 50 % phosphoric acid containing 7 % dissolved zinc oxide by weight, the surface was rinsed with water and dried. A thin layer of Nuva-Seal was applied and polymerized with ultraviolet light. Then a 2 mm thick layer of Nuva-Fil was applied on the surface and polymerized following immersion of the metal bar or hook into it. One kilogram of weight was suspended from the hooks for 8 weeks under a constant stream of water. No separation of the adhesive or the hooks from enamel surfaces was obse~wed at the end of the eighth week. Since this laboratory observation suggested adequate bonding strength of the adhesives to tolerate long-term traction, the procedure was used in the following clinical trial.
224
'~':
IRANPOUR
:.5:
,.
9 ]:
'
2.: ~
Y.2:
Fig. 1. Erich arch bar hooks are attached to tooth surfaces with Nuva-Fil.
Clinical trial Mandibular fractures, requiring intermaxillary immobilization for closed reduction, were selected for application o.f the adhesives. A t first, individual metal hooks cut from the Erich arch bar were placed on the tooth surfaces wi~h Nuva-27il (Fig. 1). Later it was found that Nuva-F[l hooks could be easily and directly hand formed oa each tooth surface and provided as much stability as the metal hooks (Fig. 2). The N u v a - F i l hook technique is simple a n d usually requires ao local or general anesthetics. Following conditioning of enamel, a thin layer of Nuva-Seal is applied and polymerized for 1 rain by exposure to ultraviolet light. Nuva-FiI is then shaped to a desired hook form directly on the tooth sur-
race and poIymerized for 1.5 to 2 rain, This procedure is repeated on all the teeth to be used for intermaxillary fixation. No waiting period is required for application of traction after the N uva-Fil hooks are polymerized. Fig. 3 shows a fracture of the right angle of the mandible which was immobilized with multiple metal hooks attached to the tooth surfaces with Nuva-Fil (Fig. 4). One of the hooks (maxillary left canine) was formed from Nuva-Fil. During 5 weeks of immobilization, with elastics on the hooks, the occlusion remained satisfactory and stable. Ot~e molar hook became detached and was rebonded without difficulty.
Fig. 3. Fracture of right angle of mandible (arrow) which was immobilized with Nuva-Fil and metal hooks technique.
~: ~ ~il ~ ~
Fig. 2. Shows Nuva-Fil hooks directly formed and t~olymerized on the teeth. A wide base and thick hook structure are formed to minimize breakage.
>:i
~:..
:
~~ (
~'~?~;?~i~!....
Fig. 4. Immobilization of fracture shown in Fig. 3, with elastics applied to metal hooks.
ADHESIVES IN ORAL SURGERY
[
225
/
Figs. 5 and 6. Fractures of right angle (arrow) and symphysis of mandible (arrow) are shown. The panorex was taken after extraction of third molar in line of fracture and just prior to immobilization. These fractures were reduced by intermaxillary fixation, using adhesives (Fig. 7).
Fig. 7. Closed reduction of fractures shown in Figs. 5 and 6 with multiple Nuva-Fil hooks and wires. A strip of Nuva-Fil is placed on mandibular anterior teeth and across symphysis fracture (arrow) for further support.
Fig. 8. The patient shown in Fig. 7, immediately following removal of Nuva-Ffl hooks and polishing of tooth surfaces. Note absence of gingival inflammatory response usually produced by conventional arch bars.
Figs. 5 and 6 are radiographs of the fractures of the right angle and symphysis of the mandible o,f a 19-year-old Caucasian male. These fractures were treated with closed reduction technique, using multiple Nuva-Fil hooks. After establishing a normal occlusM relationship, a 3 mm thick N u v a - F i l strip was formed and polymerized on the mandibular anterior teeth across the symphysis fracture to provide further support (Fig. 7). Fig. 8 shows the same case after 7 weeks of immobilization and immediately following rernoval of the adhesive hooks and strip. There is a notable absence of the gingival inflammation and enlargement usually seen with conventional arch bars. After 6 months the healing and alignment of the fractures are most satisfactory. The adhesives were also used for treatment of alveol~u- fractures and mobile and evulsed teeth. Fig. 9 shows a maxillary lateral incisor which was mobile following trauma and stabilized with a Nuva-Fil strip.
Discussion In our experience, the enamel adhesives,
226
IRANPOUR
Fig. 9. A mobile maxillary right lateral incisor,
stabilized with a Nuva-Fil strip.
when applied properly, provide sufficient strength for intermaxillary immobilization and traction. There are distinct advantages as well as certain limitatio.ns and disadvantages in the applicatio.n of the adhesives for management of some of the traumatic injuries. The major advantages of the technique, compared to the conventional metal arch bars, are lack of pain and discomfo,rt for the patient during application and no injury to the gingival tissues and the periodontium. Application o,f the adhesives, in our experience, requires no m o r e time than the other conventional methods. Simplicity of the technique of application, reasonable cost and patient's acceptance are among the other advantages. The major limitation for application of the adhesives in oral surgery is the necessity for absolute dryness, a requirement which cannot always be met in cases of oral and facial trauma. A disadvantage experienced in some of our cases was the breakage of a few hooks, but they were easily replaced. T h e breakage was most likely related to im-
proper placement technique and thin hooks. Careful placement technique, :faster polymerizing adhesives and thicker hooks will minimize the incidence of breakage. At the end of the immobilization period, the Nuva-Fil hooks and strips are easily cut off with a fissure burr, without need for anesthesia, and the tooth surfaces are restored to a high polish with sandpaper discs and a rubber wheel. This procedure can be performed by auxiliary personnel and requires little time. Further improvernent in the speed of polymerization and development of prefabricated resin hooks and bars will increase the applicability of the adhesives in management of traumatic injuries of the teeth and jaws.
References 1. BUONOCOI~.E,M. G.: Bonding to hard dental tissues. Adhesion in biological systems. Academic Press, New York 1970, p. 225-254. 2. BUONOC0RE, M. G.: Adhesives for pit and fissure caries control. Dent. Clin. Norlh Am. 1972: 16: No. 4. 3. WARD, C. T., BUO•OCORE, M. G. & WOOLRIDGE, E. D. JR.: Preliminary report of a technique using Nuva-Seal in the treatment and repair of anterior fractures without pins. N.Y. State Dent. J. 1972: 38: 269-274.
Address: Department of Dentistry The Genesee Hospital 224 Alexander St. Rochester, New York 14607 U.S.A.