Indirect bonding /certified fixed orthodontic courses by Indian dental academy

INDIRECT
BONDING

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INDIAN DENTAL ACADEMY
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Introduction
Tooth movement is made
possible by an orthodontist by
applying an optimal force.
Archwires,loops,springs,elastics,
etcrigid attachment-bracket

Bands or bonds
Bonding – several advantages and
disadvantages

Advantages -

1.esthetic superiority
2.faster and simpler
3.less discomfort to the patient
4.arch length is not increased

Bonds are more hygienic than
bands
 Mesiodistal enamel reduction
is possible
 Interproximal areas are
accessible for comp buildups
 Caries risk under loose bands
is eliminated



No band spaces are left behind
 No large inventory of bands
 Lingual brackets, invisible
braces
 Brackets may be recycled
further reducing cost



Disadvantages

Weaker attachment
 Gingival problems
 The protection against well
contoured bands is absent
 Rebonding a loose bracket
 Debonding is more time
consuming



Review

Acid etch bonding technique
Acid pretreatment-85%
phosphoric acid-1955-Buonocore
1965-epoxy resin-Newman
1968-smith poly acrylate
1970-several articles

The most widely used resin,
commonly referred to as Bowen’s
resin was designed to improve
bond strength and increase
dimensional stability by cross
linking

The indirect bonding
technique was introduced
by Dr. Silverman and
Cohen in 1972 AJO

Types of bonding
1.Indirect bonding
2.Direct bonding a. chemical cured
b.light cured composite
c.glass ionomer cement

With the indirect bonding
technique, brackets fixed to the
tooth in the working casts and
then transferred to the patients
mouth with the help of an
impression tray which is usually
made of silicone

The bonding procedure in short
1. cleaning
2. enamel conditioning
3. sealing
4. bonding
a. transfer
b. positioning
c. fitting
d. removal of excess

Cleaning
pumice- plaque and organic
pellicle
rubber cup or polishing brush
bristle brush – more effective
but has certain disadvantages

Enamel conditioning
A. moisture control

After pumice-salivary control and dry
working field
1.cheek
retractors
2.saliva
ejectors
3.tongue
guards with bite blocks
4.salivary duct obstructers [dri-angles
–parotid]

5. Cotton or gauze rolls
6. antisialogoguesbanthine,probanthine,
atropine sulphate etc
..both tablets and
injections
..PB inj are no
longer advised
..antisialogogues are generally not

banthine tab-50mgs/100lb-15
minutes before bonding
 only under supervision of the
patients physician
 contact lenses should be
removed-until next day



B.enamel pretreatment
Conditioning solution[37%
phosphoric acid for 15-60 sec]
Etchant rinsed off
Salivary contamination-not
allowed. If it occurs water spray or
re-etch for a few seconds; the
patient must not rinse

Next the teeth are
thoroughly dried with
moisture and oil free
source to obtain the well
known dull, frosty
appearance

Good bond strength is
dependent on
1.avoiding moisture
contamination
2.achieving undisturbed
setting of bonding adhesive
3.use of a strong adhesive

Sealing
Nothing but an intermediate
resin
Teeth dry-thin layer of sealant
Foam pellet or brush with a single
gingivo- incisal stroke
The
sealant coating should be thin and
even

Bonding
The easiest method of bonding..
1. transfer
2. positioning
3. fitting
4. removal of excess

a slight bit of excess is
necessary
 excess adhesive should be
removed
 excess adhesive when not
removed-discolored
 the first three procedures are
the same for direct and indirect
bonding techniques



Indirect
bonding..

Originally described by Dr.
Silverman and Cohen
several techniques-the brackets
are attached to the teeth on patients
model, transferred to the mouth with
some sort of tray to which the
brackets get embedded and then
bonded simultaneously

The clinical procedure
The techniques differ ..the way brackets are attached
to the model
..type of transfer tray
..adhesive or sealant used
..the way transfer is removed

An over view of the indirect
bonding technique
a. Take an impression and pour
with stone. Model-dry. Long axis
and occlusal height
b. Select brackets
c. Apply water soluble adhesive
d. Position the brackets

e. Mix putty silicone and press it
onto the cemented brackets
f. Immerse model and tray in hot
water. Remove any remaining
adhesive
g. Trim the silicone tray and
mark the midline
h. Prepare the patients teeth
i. Load adhesive-bracket base

j. Seat the tray on the prepared
arch-3 minutes
k.Remove tray after 10 min. tray
must be cut longitudinally or
transversely
l. Complete bonding by careful
removal of excessive flash

Modifications
Several methods – bonding
resins, sticky wax etc
Dr. Michael.D.Simmons-1978April-JCO-caramel candy softened
and preloaded in syringe.
Small amount of caramel is
warmed to approx 500c –loaded
0
preloaded syringe- 50 c-5min

A small amount is squeezed
onto each tooth to be bonded. The
brackets are then held with cotton
pliers warmed slightly in Bunsen
burner and then placed on the teeth.
Rest of the procedure is similar
Disadvantage of sticky wax.
Advantage of caramel candy

2.Since one of the major
difficulties with indirect bonding…
double tray techniqueElliott.M.Moskowitz and Douglas
Knight-1996 may JCO
Thermal cured composite
[unlimited working time] and vinyl
polysiloxane [flexible but highly
accurate under tray]

Apply thermacure composite to
the mesh pad of each bracket-cast.
Cast in heated oven -15 min at
o
325 F. After cooling remove.
Apply vinyl polysiloxane over
thermally cured brackets.
Adapt the vacuum formed Essix
clear thermoplastic material over the
cast, brackets and under tray comp.

Chair side bonding
procedure.
1. Lightly abrade adhesivediamond bur or simply scrape
2. Isolate, etch, rinse and dry as
usual.
3. Apply bonding agent-tooth
and adhesive –bracket bases and

4. Remove the clear over tray.
5. Tease the flexible under trayexplorer or scaler without
dislodging the brackets.
Advantages…
The under trays are accurate,
stable and compact and will not
dislodge the brackets from teeth
when removed

3. Light cured indirect
bonding.
JCO-1998-Aug-Michael Read
Transfer tray-silicone based,
addition cured elastomer [Memosil]stiff enough but easily removed .
1. Coat labial surface of teeth
with thin layer of Poly vinyl acetate

2. Brush a thin layer of unfilled
resin onto each bracket base-light
cure it for 30 sec.
3. Add the filled composite to
bracket bases-brackets on the casts.
4. Cure each bracket-30 sec
from occlusal and 30 sec form
gingival.
5. Adapt the transfer tray.

6. Soak the tray in cold water for
20 min.
7. Etch the teeth to be bonded as
usual. Paint thin layer of unfilled
resin over the etched enamel and
over the cured composite
8. Place the transfer tray in the
mouth and light cure each tooth for
30 sec.

4.Thermal cured, fluoride releasing
indirect bonding system.
JCO-1998-Feb-Sinha,Nanda
Modification of previously
described IB with Therma cure.
Failure to remove excess
adhesive-accumulation of plaque.
Even when excess plaque is
reasonably removed-deposits .

The only modification in
this technique is we add
Maxicure sealants A and B. This
sealant contains hydrofluoric
acid in its monomer thereby
preventing caries

5. Adhesive precoated
brackets
JCO-1993-March by Ronald B
Cooper.
Except for the APC brackets the
rest of the procedure is similar

6. Sondhi indirect
adhesive
AJO-April-1999
why a new adhesive
A new resin with higher
viscosity [fine particle fumed
silica filler]
Setting time-30 sec
Complete curing in 2 min

The lab procedure
Working models
Separating medium-1 hour
APC brackets-removed
directly from the sealed blister
If non coated bracketsTransbond XT light cured adhesiveplaced on mesh pad

Remove the excess cement.
Cure the resin
Significant undercut areas are
blocked with wax.
Bonding trays are formed-either
double tray technique or with
silicone transfer material.
Cure it again to ensure that any
uncured resin is cured

The bonding procedure
Initial preparations
Micro-etching unit – sand blast
Contamination of custom
adhesive bases –acetone and air dry
MIP is optional
Sondhi Indirect adhesive – resin
A[tooth surface] and Resin B[resin
pads]

Position the tray over the teeth –
equal pressure- 30 sec- 2 min
Remove Tray with scaler- from
lingual to buccal
Repeat the procedure for the
opposite arch

Main indication lingual
Early 1970s – Dr Craven Kurz –
Assistant Professor of occlusion and
gnathology
Plastic lee fischer brackets –ant. and
metal for post.
Shearing
force – debonding Uncomfortable to
the tongue

Turning point – ant.
Inclined plane – shearing
force to intrusive force –
intrusive and labial


Difficulties and modifications
Tissue irritation and speech
earlier vs current brackets
smooth exteriors – normal
activity
 Gingival impingement
earlier-broad bonding baseadequate oral hygiene,self
cleansing-compromised



The bases now-incisally and
mesio distally wide
Additionally gingival hooks
were redesigned so that they
are shorter and also away from
the gingiva

Occlusal interference
Predominant problem-shearing
force- upper ant brackets
 Redesigned with inclined plane
 Location of inclined plane..



Base pad adaptation
Accurate contour of base pad
not only improves the retentive
capability but also the accuracy of
bracket placement – quality of
treatment

Appliance prescription
Early 1970s – Andrews –
straight wire
 In-out varied dramatically-to
adjust this purely by bracket
design ?
 First order bends – where?



Wire placement
Access for wire
placement is limited from
lingual aspect.
Redesigned – widening
the mesial opening

Gingival hooks
They are an integral part
of lingual appliance therapy.
Original hooks were
larger-redesigned – smaller
and away from gingival
margin

Generation of brackets
First generation - 1976
Flat maxillary Occlusal bite
plane.
Premolar brackets were low
profile.
No hooks on any bracket

Second generation- 1980.
Hooks were added to all
canine brackets.
Third generation – 1981.
Hooks were added to all
anterior and premolar brackets

Fourth generation – 1982-84.
Low profile anterior bite
plane.
Hooks were optional –
depending upon treatment plan
and hygiene requirements

Fifth generation – 1985-86
Inclined plane – more pronounced
Greater labial torque – max
incisors
Hooks were optional
Sheath for TPA was available
Canine inclined plane-bi beveled



Sixth generation–1987–90.
Inclined plane – square shaped
 TPA sheath was optional
 Hinge cap attachment for
molar



Seventh generation-1990
0nwards

Inclined plane is heart shaped
 Premolar brackets – wider
mesio distally with shorter
hooks
 All hooks have greater recess –
ease of ligation



Situations where lingual
therapy is advantageous 1. Intrusion.
2. Max arch expansion .
3. Max molar distalisation

Intrusion
Brackets closer to c res.
Intrusive forces closer to c res.
Bite plane effect – active
intrusion on ant and passive
extrusion of post

Maxillary arch expansion
although not clearly
understood,clinically…
possible reasons-1. Centrifugal force
2. Thickness of brackets
3. Shorter IB span could
also be a possible cause

Maxillary molar
distalisation.
Lingual attachments are
closer to the c res.of the molar –
which is found corresponding to
the palatal root of molar

Laboratory techniques.
1. CLASS system.
2. TARG system.
3. HIRO system.

The CLASS system
1. Accurate impressions –
die stone.
2. Duplicate the cast .
3. Prepare a diagnostic set-up
– arch form,ant. Tip torque,
alignment etc
4. Clean the lingual surface –
apply separating medium

6. Mount the model on model
holder with Occlusal plane
parallel to horizontal reference
plane.
7. Brackets are attached to the
set-up cast – two part heavy body
composite.
8. Transfer brackets to
malocclusion cast – light cured

9. Brackets removed from
set-up model and attached to
malocclusion model – water
soluble adhesive.
10. Hot oven for 1 hour.
11. Remove the light
cured resin and fabricate
transfer – biostar machine

12. Place the cast in warm
water for 30 min – remove the tray
13. Abrade the composite
slightly.
14. Trays are labeled and
placed in a clean sealed plastic bag

The TARG system.
Torque angulation reference
guide – ORMCO 1984.
Capable of positioning the
brackets at specific heights.
Consists of a torque gauge middle of labial surface.
A torque blade is used to orient
the brackets

The horizontal blade of TARG
gauge – bracket slot – moved
towards varnished model.
The gap – packed with a filled
resin – custom made bracket base
which accurately fits the lingual
surface is made.
Transfer tray fabricated

Advantages
Permits more accurate
placement of brackets
 Decreases chair side time
 Less patient discomfort
 Esthetically more pleasing
 Incidence of caries is less



Avoiding band fitting on
posterior teeth
 Improved ability to bond
posterior teeth



Disadvantages
Technique sensitive
 Additional set of impressions
needed
 Posterior attachments more
likely to fail if the patient
chews ice etc



Removal of adhesive is more
difficult and time consuming
 Risk for adhesive deficiencies is
greater
 Failure rates seems to be slightly
higher



Extensive laboratory work
required
 Risk of debonding is high



Conclusion
when the laboratory and the
clinical procedures are strongly
adhered,indirect bonding is
undoubtedly a valuable technique. It
proves itself by saving chair side
time which is the most valuable for
a practitioner.

If not for the labial technique,it
is definitely a boon for the
lingual operating system

Thank you !

Indirect bonding /certified fixed orthodontic courses by Indian dental academy

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