Thanx to Dr. Goraya sir for his article have been used in my seminar. thank you so much sir

1. INDIRECT BONDING in lingual orthodontics
PRESENTED BY- DR. PARAG S. DESHMUKH

2. INTRODUCTION:
• In September 1972, method of direct bonding was
introduced in orthodontic profession.
• Most current concept of indirect bonding technique are
performed around the procedure developed and perfected
by Doctors.
Morton Cohen
Elliott Silverman
• Both the doctors are responsible for bringing the direct and
indirect bonding technique into being in the year 1972 and
1974 respectively.

3. • The main advantage of indirect bonding over direct bonding is
that the brackets can be positioned more accurately in the lab
and the clinical chairside time is decreased.
• However this method is technique sensitive.
• Reasons for difference in bond strength between direct and
indirect bonding may be-
 Bracket bases may be fitted to tooth surface with one point
fitting by placement scaler
 A totally undisturbed setting is obtained more easily with
direct bonding.
• However when correct technique is used, failure rates with
direct and indirect bonding fall within clinically acceptable
range.

4. Indirect bonding technique in lingual orthodontics:
• Several techniques are available for indirect bonding most are
based on the procedure introduced by Silvermen and Cohen.
• The brackets are glued with temporary material to the teeth on
the patient’s model, transferred to the mouth with a tray into
which brackets get incorporated, and then bonded
simultaneously with bis-GMA resin.
• However most recent IBT are based on modification introduced
by Thomas.
• In this technique brackets are attached to teeth on model with
composite resin to form a custom base.
• These brackets are then transferred to the patient’s mouth with
a transfer tray and then bonded with chemically cured sealent.

5. • It can be curious to know that initially it was used the famous
candy Sugar Daddy, softened with heat, to glue the bracket to the
working model.
• The technique most widely used today is that of the composite
coated base attachment, on individualized dental anatomy,
created in the laboratory.

6.  IBT is a two stage procedure-
• 1st stage is carried out in the laboratory, where brackets
are placed and attached to a plaster model of the patients
teeth.
• Different types of custom base composites may be-
 Light cured
 Chemically cured
 Thermally cured
• Silverman et al. (1972) used an unfilled
methylmethacrylate-based adhesive (BisGMA) in order to
bond plastic brackets onto a model

7. • Silverman and Cohen (1975) improved this technique by using a
perforated mesh base and ultraviolet (UV) cured BisGMA resin.
• A liquid catalyst resin is applied during chairside bonding onto a
composite layer that has been pre-cured in the laboratory (filled
BisGMA adhesive).
• A thin layer of sealer is additionally bonded onto the enamel.
The chemical curing process begins when both components are
brought into contact with each other on placement of the tray.

8. • One of the criticisms of this method was that complete
polymerization did not occur. For this reason, a modified
technique was developed, with both components mixed
before application (Hickham, 1993; Moskowitz et al.,
1996;Miles, 2000).
• Other techniques make use of water-soluble adhesives for
placing the brackets in the laboratory setting. This adhesive is
removed after creation of the transfer tray (White, 1999).

9.  In 2nd stage the bracket in their position are
transferred by mean of a tray to the patients
mouth. Where they are positioned by relating the
tray to the occlusal surfaces of the teeth on the
etched enamel surface of the teeth.

10. General Consideration:
•Patient selection:
Cases those exhibit short clinical crown height, severe
rotations or bad oral hygiene are not suitable for I.B.T.
•Selection of temporary adhesive:
It is used to hold bracket to the working cast, if setup is
going to be completed by a technician in lab, use of available
water soluble temporary adhesive is used.

11.  Bonding adhesion :
• One system from reliance orthodontics recommends the use of
thermally cured base composites i.e. Thermacure, enhance
adhesion booster, and a chemically cured sealents i.e. custom
I.Q.
• Another system from 3M Unitake recommends the use of light
cured base composite i.e. Transbond XT and chemically cured
sealent i.e. Sondhi rapid set.

12. • Tray materials:
 Its important to keep in mind that the tray material must be
easy to use, the tray material must flow around the bracket as
completely as possible.
 The types of tray used are- Opaque or Nonopaque
 Materials used to make the transfer trays are- Polyvinyl
siloxane, custom made acrylic resin trays, light polymerized
resin composite trays etc.
 According to the extent they can be for single tooth, full arch
or sectioned full arch, double tray system.

13. Stages:
1. Impression appointment:
Standard and good impression are taken with an
attempt to minimize porosities.
2. Laboratory procedures:
Impression are poured in hard dental stone and
these working model must be dry when utilizing the
adhesive for bracket placement. Mark the long axis
of each tooth with a soft pencil and also the height at
which bracket has to be placed.

14. • Bracket preparation:
 Each bracket is approximated to the appropriate
tooth surface and inspected for contour and pad
placement. If the bracket is overcontoured, it can
be flattened.
 After the bracket have been adapted they are
placed on a tooth surface of model by using
adhesive material.

15. Variou systems ofLingual bracket
placement
These include:
1. Torque angulation reference guide (TARG).
2. Fillion’s indirect bonding system.
3. The customized lingual appliance setup service
(CLASS) system.
4. Hiro system
5. The Ray set system
6. Lingual bracket jig

16. Torque angulation reference guide
(TARG)
•This technique of bracket placement was developed
by Ormco in 1984.
•It permits bonding of brackets in the laboratory, at an
accurate distance from the occlusal edge of each
tooth with respect to a horizontal reference plane.
•A labial reference gauge is used to orient individual
teeth.
•Using only one unique angulation model, the TARG
allows pre-programming of tip and torque before the
start of treatment.

17.  Procedure: -
 A modified dental surveyor and a
torque and angulation reference gauge
are used to align the lingual surfaces
relative to the labial inclinations
 Crown long axis is marked on labial
surface.
 A gauge having the labial torque and
angulation specific for each tooth is
used to align axial inclinations relative
to marking stylus on the surveyor tooth
by tooth.
 Model is tipped on a swivel base until
the long axis of the labial face of the
tooth aligns with the specific gauge
curvature at the middle third of the
tooth

23. •Advantages:
- It is an accurate and quantified two-dimensional
system.
- Allows accurate placement of the brackets on the cast
without need to cut out the teeth and place in wax.
•Disadvantages:
- The system does not take into account the labio-
lingual thickness of teeth.
- The distance of the bracket base and the labial surface
varies according to the level of bonding.

24. Fillion’s Lingual Indirect Bonding System
• This system was developed by Dr. Didier Fillion of
France in 1987.
• Also known as ‘Bonding with Equalized Specific
Thickness’ (BEST).
• Consists of two elements: -
 TARG with the thickness measurement system.
 DALI (Dessin Del Arc Lingual informatize or
computer drawing of lingual archwire) program

25. A. Thickness measurement system:
• A caliper is added to the TARG
central axis and modified it to
present two horizontal blades.
• One is engaged into the bracket
slot and the other one applied to
labial tooth surface.
• Thickness measurement system
records the thickness(Width of
the teeth with bracket) of six ant.
teeth.
• Greatest thickness is chosen as
the standard thickness.

27. • Adhesive is applied to the
bracket base.
• The bracket, placed on blade
is moved toward the plaster
until the selected thickness
appears on the screen.
• The resin excess is removed
before polymerization
• Thickness standardization is
achieved while brackets are
supported on resin pads of
different thicknesses

37.  Advantages : -
• Eliminates the necessity to prepare a set up
• Bonding is performed directly on the malocclusion
model.
• Standardization of thickness is present
• So ,this system permits us to avoid all 1st order
bends except the ones b/n cuspids and bicuspids
and b/n bicuspids and molars.
• Reduces chair side time during arch wire bonding.

38.  CLASS system-
• Described by Scott Huge.
• This technique offers a method of lingual bracket placement
that takes into account the anatomical discrepancies in lingual
surfaces of the teeth.
• This is accomplished first by constructing an ideal diagnostic
setup from a duplicate setup model of the patients original
malocclusion.

39. • Impression must be obtained
from the patient – alginate /
rubber base impression
material & models poured in
diestone.
• Models are duplicated and
dried in the oven

55. DALI (Dessin Del Arc Lingual informatize or
computer drawing of lingual archwire) program
• From the thickness measurement of all the
ttoh with TARG it is possible to obtain a
detailed drawing of archwire with all the teeth
perfectly aligned.
• On the archform the brackets take their
positions from midpoint of triangle which
represents width of bracket, tooth and
distance between bracket slot to the labial
surface.
• Once all the teeth are represented the
program traces best fit archwire to the
triangle creating ideal archwire for perfect
teeth alignment.

57. Hiro system-
• Introduced by Hiro and later improved by Takemoto and Scuzzo.
•Method:
 Creating an Ideal Set-up:
• Take PVS impressions of the arches and pour the models with good
quality stone. There is no need to make a base at this point.

58. • After taking out the casts, cut a small
groove at the base of the model
conforming to the shape of the arch. This
groove will become part of each sectioned
tooth and will act as a guide while
positioning it back on the set-up base.
• Apply separating medium to the model and
after it has dried, pour stone in the base
former and position the cast in it, ensuring
that the cast is centered correctly in the
base former.
• Apply separating medium to the model and
after it has dried, pour stone in the base former
and position the cast in it, ensuring that the cast
is centered correctly in the base former.

59. • After the base has set, carefully tease out the model from the base. This base
will act as a set-up base
• After taking out the model, position it back
on the base. Mark the longitudinal axis of
the teeth beginning from the incisal
edge/cusp tip of the tooth to the bottom
of the base. Also number each tooth for
identification and with the diamond disk
section teeth into individual units

60. Position these sectioned teeth on the previously taken PVS impressions and pour
melted wax over them.

61. • Once the wax hardens up, carefully take out the
sectioned teeth embedded in wax as a single
unit from the impression and position it on the
set-up base.
• Now seal this assembly on the set-up base,
making sure that the previously drawn
longitudinal axesof these teeth coincides with
the corresponding lines on the base.
• This will ensure that the sectioned teeth have
been positioned correctly on the base.

62. • Draw longitudinal axes on the lingual
surfaces of the teeth.
• Also mark horizontal lines across the lingual
surfaces of the teeth indicating bracket
positioning height.
• Now complete the ideal set-up according to
the prescription by fulfilling treatment goals
and objectives.
• Depending upon the complexity of the case,
the set-up can also be realized on a semi-
adjustable articulator.

63. Procedure:
• Bend .018x.025 stainless steel wire (full
slot) conforming to the lingual shape of the
arch.
• This wire should be bent accurately by
making a small curve for anterior segment.
• Mark midline on the wire and also mark in-
between the canine and premolar.
• While bending the wire, it is important not
to introduce any torque, tip or any other
bend in the wire except for the offset bend
in the canine and premolar area or if
required, in between the second bicuspid
and molar area.

64. • Place brackets on the ideal arch wire
and apply modules or ligate it with
ligature in order to secure these on to
the wire. Now position this assembly
on the model.
• At this point, only some part of bracket
bases will be touching the palatal
surfaces of the teeth.
• Later on, the remaining space will be
filled in by applying resin to the bracket
base in order to set the desired torque,
in-out and rotations.

65. • The jigs are secured on the archwire-bracket assembly with an elastomeric ligature and
one of the jigs is bent.
• While bending, care should be taken in keeping the minimal gap between the jig and the
tooth surface so that a minimum amount of resin material is used in fabricating
individual-tooth transfer caps.

66. • Apply a coat of separating liquid to the
teeth on the cast and allow the separator to
dry before proceeding any further.
• This will not only prevent the pencil marks
from transferring on to the customized
bracket bases, but will also facilitate easy
separation customized bases from the
indirect bonding model.
• Drying the separating medium can be
hastened by placing the model in a
microwave oven for 15 seconds .
• Now position the assembly on the model
and put some light cure adhesive at the
rear end of the wire and model in the molar
area.
• Secure this assembly on the model by light
curing the orthodontic adhesive .

67. • Fabricate single-tooth transfer caps with
light cure Cement by putting material onto
each jig and tooth in the incisal/occlusal
area and some part of the labial surface.
• Avoid putting any material on the brackets
and on the vestibular surfaces of the
posterior teeth.
• Light cure the cement in order to complete
the fabrication process.
•
• At this stage, it is important to note that
customization of bracket pads is still
pending, i.e., the gaps between the bracket
bases and the lingual surfaces of the stone
model of teeth still exist.

68. • A small amount of light cure orthodontic
adhesive is put onto bracket bases, and
the jigs carrying the brackets are
positioned back on the corresponding
stone model of the teeth.
• Excess material around the brackets is
cleaned before light curing them for 20
seconds depending upon the intensity of
the light curing unit.
• This results in precise customization of
bracket bases that compensates for the
irregular and variable morphology of
lingual surfaces of the teeth.

69. • Microetch the customized bases with a Microetcher , using 50Micron
Aluminium Oxide for 2-3 seconds to increase the surface area of the base for
proper bonding .
• Be sure to clean the customized base with soap and water as leaving powder
on the base will weaken the bond strength.
• While Microetching, due care must be taken in containing the sand blasting
debris, using sandblasting chamber.
• The appliance is now ready for bonding. The operator is free to use either the
light cure composite or the self cure type while bonding the brackets to the
patient’s teeth.

70.  Advantages:
- There is no need to transfer brackets from the setup model
to the original malocclusion model.
- Accuracy is improved due to individual transfer trays.
- Bonding of one tooth is not affected by position of other
teeth.
- Rebonding is easier.

71. Ray set system
BIRTE MELSEN, DDS, DO DR. PIERO BIAGGINI JCO/NOVEMBER 2002

72. • Designed to provide maximum precision in indirect bonding
without a diagnostic setup.
• The Ray Set system is able to compensate for anatomical
deviations by modifying the bracket bases with bonding
adhesives.
• The Ray Set enables the clinician to bond preadjusted brackets so
the results reflect their prescribed values, regardless of any
variations in bracket height and shape of individual teeth.

73. Torque and Tip Calculations :
• Torque is defined as the angle formed by a vertical line
perpendicular to the occlusal plane passing through Q point
and a line tangent to the labial surface.
• The torque value is 0 when this tangent is perpendicular to the
x-axis (the Andrews occlusal plane) of the coordinate system

74. • Ray Set calculates 0 torque by inclining the tooth until the
tangent coincides with the vertical line centered on Q point.
• Starting from 0 torque, it is then possible to evaluate whether
the torque in the preadjusted bracket is sufficient to achieve
correct buccolingual root inclination, or whether it is necessary
to customize the torque by adding composite at the base of the
bracket.

75. • The tip value is 0 when the long axis of the tooth coincides
with the vertical line of the coordinate system.
• As with torque, the correct tip value is compared with that of
the preadjusted bracket.
• If necessary, the system helps modify tip accordingly.

77.  Design and Use of the Ray Set System:

81. • Orient the long axis of the tooth with the vertical rod of the mandrel,
making sure that the vertical line is a tangent to Q point (the bracket
bonding height).
• The goniometer is thus set to 0 tip

84. Use the vertical rod and laser beam to determine the tooth position
corresponding to 0° torque.

88. Lingual-Bracket-Jig System:
• The jig is useful for positioning standardized appliance brackets,
but is most useful in accurately and precisely positioning custom
brackets designed and manufactured to the specific anatomy of
the individual patient.
• The jig has the advantage of providing the orthodontist with the
capability of placing the bracket on the tooth and pressing it into
its exact position in a matter of seconds by merely holding the jig,
with the bracket-engaged, between two fingers, or by using a
small tool, and then directing the assembly into position by
pressing the lever end against the tooth with a tool or finger.
• The jig can be used for attaching brackets on either the labial or
lingual sides of the teeth.

89. • The Lingual-Bracket-Jig (LBJ) consists of a set of six jigs for the
maxillary anterior teeth (canine to canine), which present the
most morphologic variations on the lingual side, a millimeter
ruler (0.1-mm accuracy), and a wrench for in-out
adjustments.
• The ruler is used to measure the in-out bracket position,
compensating for differences in thickness.

90. High magnification of a jig

91. A lingual bracket attached to a jig.

93. References:
• Lingual orthodontics – Romano
• Slide no.- 58 to 69: Getting started with lingual: understanding and managing your
labwork with self-ligating evolution brackets; Kulbir Singh Goraya;
www.lingualnews.com, Vol 6 No. 1, August 2008.
• Indirect bonding — a new transfer method. B. Wendl , H. Droschl and P.
Muchitsch, European Journal of Orthodontics 30 (2008) 100–107
• INDIRECT BONDING IN LINGUAL ORTHODONTICS - A REVIEW, Prabhuraj B
kambalyal, Vol. - III Issue 4 Oct – Dec 2011, aedj.
• Modified bonding technique for a standardized and effective indirect bonding
procedure. Fabio Ciuffolo, Nicola Tenisci, and Luca Pollutrib. (Am J Orthod
Dentofacial Orthop 2012;141:504-9)
• The Ray Set: A New Technique for Precise Indirect Bonding; BIRTE MELSEN, DDS,
DO DR. PIERO BIAGGINI; JCO/NOVEMBER 2002
• Bracket placement jig assembly and method of placing orthodontic brackets on
teeth therewith- A patent.
• An insight into orthodontic indirect bonding technique. By Dr. Francesca
Muggiano , Dr. Ivana Giannantoni , Dr. Giorgia Calicchia; 06 Jan 2014; Webmade
central.

94. Conclusion:
• Surely the indirect bonding technique can be proposed as a routine
everyday procedure for the easiness of execution and the reduction
in clinical working time.
• Careful study of available information by the orthodontist will be
mandatory in keeping up with progress.

95. Thank you