Orthodontic Bonding; A Direct Approach

8/13/2019 Orthodontic Bonding; A Direct Approach

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Bowman

CLINICAL Orthodontic Bonding A Direct Approachs Jay Bowman, D.MD. , M .S.D.Adju nct As sociate Professor,Department of Orthodontics,Saint Louis University, Saint Louis, MO. ,Straightwi re instructor,Th e University of Mi chiga n, Ann Arbor, MI.

Abstract Both direct and indirect bonding techniques have associated benefits and disadvantagesMild improvements in bonding accuracy when using indirect bonding have been proposedto outweigh the additional procedures and costs The advent of efficient pre-pasting and lightcured adhesives have improved direct bonding. It appears that to select one or the othertechnique is a more of practice management decision since excellent clinical results can beachieved with either A comparison of the two techniques along with recommendations forsimple improvements to the direct technique are presented

Keywords Direct bonding, indirect bonding, light cured adhesives

The advent of bonding adhesives for orthodontics hasbeen one of the most significant changes in the historyof the specialty. At the outset, the accuracy of di rectbonding of orthodontic brackets was restricted by thel imited working t ime of the first generation ofcomposite resin adhesives. In efforts to work withinthe constraints presented by the materials and toimprove the accuracy of bracket placement, indirectbonding methods were developed. These procedureswere also especially suited for lingual orthodontics dueto significant variations in lingual dental morphology.With the subsequent introduction of light-curedad hesives and their virtually limitless working time,more precise and yet efficient direct bonding becamefeas ible .Sondhi has stated proper bracket positioning is acritical part of co ntemporary orthodontic treatment,espec ially if some type of pre-adjusted prescription isutilized. This is true whether brackets are directly orindirectly placed. Despite the us e of so me type oftraditional dental surveyor, intraoral measuring device(e.g., Boone gauge, positioning jig), or computerass isted "tooth-targeting system" for bracket placementand regardless if a technician, assistant, or theorthodontist places the brackets, it is the orthodontistof-record that is ultimately responsibl e for that precisepositioning.Although there appea rs to be no difference in shearbond strength between brackets that are bonded direct ly

or indirectly2 there does seem to be a difference ofopinion as to the level of accuracy that ca n beachieved with each. It would seem that brackets thatare placed on dry stone models, using a precision"measuring gauge," in the quiet and well-lit confinesof a laboratory (rather than the more turbulent oralenvironment), should be more accurately positioned.In fact, those with more than just a passing academicinterest in the indirect technique claim that theirbracket placement is, indeed, significantly moreprecise.34 s In co ntrast, Hodge and co-workers6concluded that mean bracket placement errors weresimilar for both directly and indirectly bondedappliances. Similar findings were reported by Koo etal. / however, the indirect technique did demonstrategreater accuracy for bracket height.If , however, we are simply splitt ing hairs (i.e.,meas uring fractions of millimeters in bracket position),then perhaps we should also take into equally seriousconsideration the much more substantial errors inherentto co ntemporary orthodontic treatment: errors indiagnosis/treatment plannin g, tolerances inmanufacturing of brackets and wires, the fact thatbracket prescriptions and bases are designed for the"average" tooth, and even the limited precision of archwire bending during treatment. It is the accumulationof these errors that must be eliminated duri ng treatmentin order to achieve an ideal result at the conclusion. aTherefo re, any slight, but statistically significantimprovement, derived from indirect bonding accuracy

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may, at the end of the day, ofte n be c l ini ca ll yin signi f ica nt. It is somew hat li k e pur c has in g acomponent ste reo syste m to liste n to music. You canpu rchase the most elaborate and sophi sticated CDplayer or ampl ifier but if you have substandard spea kersor w iring then the end resu lt is a less than idea l liste nin gexperience; at least for the discerning aud iop hil e. Inother words, an attenti on to detail in all aspects ofort hodontic ca re not ju st bracket placement, appearsa reasonable expectation.Conseq uently, the choi ce between direct or indirectbonding appears to be more of a practice managementdecision than a treatment imperative. As such, we mightthen evaluate these two techniques in terms of a cost/benefit analysi s without fear that patient care willso mehow be eg reg iously affected by our se lect ion.Comparing the Clinical Procedures -At first glance,the clinica l procedures for direct and indirect bondingare distinctly di ffe rent; however, they appear to havemany similarities when compared to one another interms of the steps req uired fo r each:Direct bonding - isolation, access, visuali zat ion ,adh es ive app li cation , individu al bracket placement,flash-removal, and ad hes ive curing.Indirect bonding - i so lat io n, access, ad hes iv eappli cat ion , bracket tray placement, adhes ive curingand flash-removal.If light-cured ad hes ives were pre-applied to the bracketsprior to their placement on teeth, for either the indirector di rect technique, then both methods would benefitfrom one less c linica l procedure. Otherwise, th eprincipal c lini ca l differences between these tw otechniques appear to be threefold: the mode of bracketplacement, cost, and flash-removal.Although a dental ass istant ca n faci I tate e ith ertechnique, direct bonding requires more chair sideminutes. Thi s appears to be, at minimum , eq ui tablybalanced by time spent by a labo rato ry tech ni c ianperfo rmin g th e spec iali zed procedures of bracketplacement on models and transfe r tray fabr icat ion forthe indirec t technique. Co nsid e rin g that bothtechniques also us e the same devices for iso lat ion ofthe dentition and th e sa me ad hes ives, then thedifference in cost is directly related to materi als andequipment required for the labo ratory procedures ofthe indirect technique.

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J Ind O rthod Soc 2004; 37:137-145

Light-cured AdhesivesWh en using light-cured adhes ives the dental ass ista ntca n initi all y place all of the brackets on the teeth. Inthismanner the orthodontist s chair side t ime is reducedto simply the fi nal positioning of those brackets. Thi sdoes require a few more minutes than the indirectplacement of an entire tray filled w ith brackets. Ineither case the orthodontist is still responsib le for thefinal positioning, w hether that is accompli shed on asto ne model or directly on the teeth. Conseq uentlythe ort hodo nt i st s time co mmitm ent appears toequ ivalent for either technique, but the practitioner ca ndecide to spe nd those few minut es either in thelabo ratory or chair side with the patient.A similar situation ex ists for the remova l of the excessbonding ad hes ive that is expressed f rom under thebracket as it is seated onto the tooth. For the directtechnique, this f lash is removed ju st prior to the finalpositioning of eac h brac ket and befo re li ght-cureact ivation. At thi s stage, the soft ad hesive is easi Iyremoved with simply a dental scaler. In co ntras t,hard ened flash is removed only after curing of thead hes ive for the indirect technique. Thi s may be amore tedious and time-co nsuming procedure, oftenreq uiring the use of rotary instruments.If the add ed cost of materials, co mmitm ent to theintermed iate laboratory procedures and more difficultflash removal appear balanced with a slight ly moreaccu rate bracket placement, then the se lect ion ofindirect bonding is an easy one. If, however, th eo rthodontist realizes that some individu alized wirebending, bracket repos itioning, and occasional use ofa custom tooth positioner,loare on the horizon, no matte rthe bonding technique se lected, then a direct approachmay be ultimately simpler, eas ier to teach auxili ari esand more economical to co nsider. Especia ll y sincepatients do not all exhibit fully erupted dentitions{w i thout c rowdin g or ro t ations} and they mayi nadvertentl y shea r-off a few br ac kets d uri ngtreatment, so me di rect bonding may be an in escapableeventuality during typical orthodontic care anyway.With that in mind, it is not the purpose of thisco mmunica tion to rev isit th e numerous refe rencespr ov idin g sup erb instru ct ion in bracket bondingtec hniqu es,ll ,1 13 but rather, to provide so meenhancements to the already established protocols fordirect bonding.


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Enhancements to Direct BondingIsolation Access and VisualizationSimply stated: if you cannot clearly see the tooth, youcannot accurately place a direct bond. Isolation ofteeth to prevent contamination is also an issue for bothdirect and indirect bonding. In addition, ambient light

Figure 1: An ope rato ry li ght f il ter (SafeVu, AmericanO rth odo nti cs, Inc., Sheboygan , WI), co nstru cted fromtranslucent o range ac ryli c, prevents prematurepolymerization of li ght-cured bonding ad hes iv e and yetprovides adeq uate light for accu rate bracket placement. Thefilter is rotated into place, over the light source, only whenneeded.

Figure 2: An adjustable cheek expander (WYRED, GlenroeTechnologies, Inc., Bradenton, FL) produces both buccal anddistal forces for improved access to posterior tee th duringdirect bonding. The terminal end of the spring stee l wire ca nbe used as a finger rest to app ly more retraction to th e cheekon the side where brackets are being appli ed

Bowman

Figure 3: Pre-pasting orthodontic brackets w ith light-cureadhes ives, during assistant downtime, provides an economica lmethod of improving the efficiency of direct bonding. Afterad hes ive is applied, the bracket is placed onto a speciallytreated ca rd to prevent loss of the adhesive when the bracketis subseq uently removed (Slippery Bond Ca rd , AmericanOrthodontics, Inc., Sheboygan, WI). Cards are prepared withbrackets spec ifically se lected for a patients individual trea tmentplan. These ca rd s are sto red in a light safe that is transportedto the ope ratory (Safe Box, American Orthodontics, Inc.,Sheboygan, Wi). A work box , const ru cted from orangetranslucent ac ry li c, prevents polymerization of li ght- cureadhes ives by ambient light during the pre-pasting process(Work Box, American Orthodontics, Inc., Sheboygan, WI )

Figure 4. Direct bonding tray includes a slippery ca rd withpre-pasted brackets (Slipp ery Bond Card , AmericanOrthodontics, Inc., Sheboygan, WI). An orange acrylic coverover the bracket ca rd prevents premature polymeri za tion ofthe adhes ive (Chairside Cover, American Orthodontics, Inc.,Sheboygan, Wi)

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igure 5 : Verti ca l o ri enta ti o n of brackets is the mo stproblemat ic issue w hen direct bonding. A Boone ga uge orsome derivative is often used to meas ure the positi on of theedgewise slot from the incisa l edge or cusp of th e tooth

igure 6: Alternat ives for vert ica l bracket orientat ion: 1) ave rti ca l slot gauge or disposable measu ring s tick (clampedinto a needle holder) is used to measure the incisa l edge oft hebrac ket to the incisa l edge or cusp of the toot h. 2) a disposablemeasuring tape, also used to meas ure the bracket edge to theincisa l edge or cusp. Both devices are placed direct ly on thefacia l surface of the tooth to red uce the rotat ional erro rs inherentw ith Boo ne-t ype gauges (B racke t ga uges, G lenr oeTec hnolog ies, Brandenton, FL; Butte rfly Bracket System,Ame ri ca n Orthodontics, Inc., Sheboyga n, WI)

and operatory lights may prematurely reduce workingtime w hen light-cured adhes ives are used. Therefo re,some simple improvements in th e clini ca l equi pmentinvo lved may significa ntly enhance d irect bonding.

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J Ind Orthod Soc 2004; 37: 137- 145

igure 7: A f il ter lo ll ypop to prevent p rematurepo lymeri za tion of l ight-cure ad hes ive from amb ient li ght isheld over the brackets immediately after their ini tial placement.Thi s dev ice is removed w hen the ort hodontist adjusts thefinal bracket positions

igure 8: App ly in g flu ori de va rni sh (Duraf lor, Ph arma-sc ience, Inc., Montrea l, Ca nada) immed iate ly after direct bondprocedures helps to reduce enamel deminerali zat ion les ions.A thin coat ing of va rni sh is pa inted on the surfaces of theteeth, ad jacent to the brackets, using a mi niature spongeapp li cato r { \Iigure 9. A simple tray set-up fo r the re-app licat ion of a

fluo ride va rnish at 3-4 months in te rva ls during orthodonticsto help red uce the potential fo r enamel sca rs. O nly toothbrushin g, iso lation , and drying of th e enamel are requiredpr ior to reapplica tionA n ope rato ry li ght f il te r (SafeVu, A m eri ca nO rthodontics, Sheboygan, WI) (Figure 1) and adjustableli p/c heek ret rac to r (WYRED re tr ac tor, G lenroeTechnologies, Bradenton, FL)(Figure 2) are two simple


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devices that were designed to improve this situation.The light filter is constructed of translucent orangeacrylic and is placed directly in front of operatory lightsto filter the light frequencies that would prematurelypolymerize light-cured adhesives, while still providingadequate illumination for accurate bonding.Although hydrophilic adhesives, glass ionomers withpolyacrylic acid etch, and self-etch primers14 havegained popularity in recent years, they are not withouttheir own inherent limitations. For example, Swartz15has stated, the preponderance of the studiesinvestigating these materials with and withoutintentional water or saliva contamination suggests thatthey do not compensate for poor bonding procedure orsaliva contamination. In other words, placing resinsealant or primer onto etched enamel prior to salivarypellicle formation is criti cal whether using a direct orindirect approach with any adhesive. 6A simple, yet adjustable, cheek expander produces notonly lateral forces but also distal retraction of the lipsto increase visibility and access to the posterior buccalsegments. The force of expansion produced by the steelspring wire of the device can be adjusted and theterminal wire portion is used as a finger rest to improveretraction on only the side of the patient where a bracketis being directly applied.Pre-coating BracketsThe introduction of light-cured adhesives, featuringincreased working times, immediately improved theaccuracy of direct bond placement. In fact, a dentalassistant can place these adhesives on all of the bracketsto be used for a particular patient, hours or days beforetheir appointment. In this manner, the chair side timerequired for each patient is reduced. A word box,constructed using orange light filter plastic, preventsambient light from prematurely curing the adhesive asit is applied on each bracket (Work Box, AmericanOrthodontics, Inc., Sheboygan, WI) {Figure 3.17An assistant selects only the specific brackets18.19neededfor a particular patient's treatment plan before applyingthe adhesive (e.g. premolar brackets are not pre-pastedif these teeth are to be extracted). The pre-pastedbrackets are then placed on a specially treated card(Slippery Bond Card, American Orthodontics, Inc.,Sheboygan, WI) to prevent adhesive dislodgement fromthe bracket base when the appliances are later removedfrom the card during direct bonding. The individual

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bracket cards are then stored in a light safe storagebox along with cards for other patients to be bracketedthat week (Storage Box, American Orthodontics, Inc.,Sheboygan, WI) (Figure 4).Accurate BracketingThe vertical position of brackets is the most problematicaspect of direct bonding. In comparison, mesial-distalpositioning and long-axis orientation h ve beenreported to be just as accurate as found with indirectbonding.7 Consequently, some type of measuring devi ewould seem to be a prerequiste to precise positioningof brackets with the direct technique.

The typical device used to measure vertical bracketposition is the Boone gauge or some derivation thereof(Bracket Height Gauge, Glenroe Technologies,Bradenton , FL (Figure 5). In general, these gauges areto be placed at a right angle to the labial surface of thetooth in the anterior region and parallel to the occlusalplane in the posterior. Unfortunately, undesireddeviations in bracket position are possible if the deviceis not angulated properly. An alternative is to measurealong the facial surface of the tooth from the incisaledge of the bracket, instead of the slot, to the incisaledge or cusp (r(Figure 6). In this manner, rotationalerrors are minimized; however, a different bracketpositioni ng chart for your bracket prescription wi needto be created.End Game: Flash Removal, Curing, andFluoride VarnishAn orange acrylic filter can be held over the seatedbrackets to prevent premature polymerization fromambient light until the orthodontist performs finalpositioning (Mouth Shield, American Orthodontics, Inc.,Sheboygan, WI) (Figure 7). Excess bonding material orflash is easily removed during final bracketpositioning and prior to polymerization of the adhesive.A simple dental scaler hand instrument is placed in thebracket slot to orient it on the tooth surface and servesdouble duty to remove the expressed adhesive aroundthe bond margins. This is undoubtedly less timeconsuming and potential more comfortable for thepatient than using a rotary instrument to removehardened adhesive, as required by the indirecttechnique.There are a number of options available for initiatingthe polymerization of light-cured adhesives (e.g.

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haloge n,2 LED , plasma lights, and lasers . Recently,argon lase rs have bee n shown to significa ntly decreaseenamel demineralization.21.22 Th erefore, if the cost ofthese lase rs becomes affordable, they may becomemore prevalent in orthodontic practice. Until that time,the routin e app li cat ion of a fluoride dental varnishDur af lor, Pharm asc ience , Montreal, Canada )

immed iately after the placement of brackets, with reapplica tion eve ry 3-4 monthsduring treatment, has beendemonstrated to provide so me reduction of enameldemi neral ization. 23 24A thin coating of varnish is painted on the exposedenamel of the facial surface, immediately after lightcuring of brackets and while the teeth are st ill dry {Figure8 . 25 The ad ded minute or so of time and low cost ofthis material is worthwhile, especia lly if it might preventor at least diminish the prevalent and unaestheti cdilemma of enamel scars. Periodi c re-application ofvarnish only requires simple tooth brushing and isolation.For that reason, it can be easily incorporated into routineorthodontic adjustment visits Figure 9 .Direct or Indirect: Is That Really theQuestion?Both direct and indirect methods of orthodontic bracketplacement can produce accurate and favorable results.Some difference in procedures and costs are the majordeterminants in selecting one method over the other.Objective self-assessment of finished cases e.g., ABODiscrepancy Index,26 PAR Index27 ) and/or peer-reviewedevaluations e.g., American Board of Orthodontics orAngle Society examination , study clubs, casepresentations), combined with an attention to detail inall aspects of orthodontic care, seem to be just asimportant electives. Their utilization may help to avoidstagnation in practice and repetition of the same errors,while simultaneously optimizing improvements infinished results for orthodontic patients. In other words,the only way to assess the accuracy of your finishedcases, including your chosen bonding technique, is tomeasure the outcomes and then fine-tune your treatmentprocedures as a result.*Orange box system, SafeVu light filter, and ButterflySystem are available from American Orthodontics, Inc.,1714 Cambridge Ave. , Sheboygan, WI. 53082.

WYRED cheek retractor and bracket position gaugesare available from Glenroe Technologies, 1912 44 th Ave.Eas t, Bradenton, FL 34203.

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D ur af lor fluoride varnish from PharmascienceLaborato ri es, In c., 10 Orchard Pl ace, Tenafly, NJ 07670is ava ilable from mo st dental suppliers.Commu n icationsS. Jay Bowman1314 Wes t Milham Ave.Portage, MI 49024e- mai l: drjwyred@aol. comRe ferences1. Sondhi A. The impli cations of bracket se lection

and bracket pl acement on finishing details. SemOrthod 2003;9:155-64.

2. Yi GK, Dunn WJ, Taloumis LJ. Shear bond strengthcomparison between direct and indirect bondedorthodontic brackets. Am JOrthod Dentofac Orthop2003;124:577-81.

3. Sondhi A. Efficient and effective ind ire ct bonding.Am JOrthod Dentofac Orthop 115:352-9.

4. Machata B. Indirect bonding: Custom base - Avehicle for change. Am Orthod. Good Pra cti ce2003;4{1 ):5-7.

5. Melsen B, Biagg ini P. The Ray Set: A newtechnique for precise indirect bonding. JClin Ortho2002;36:648-54.6. Hodge TM , Dhopatkar AA, Rock WP, Sp ary DJ. Arandomized clinical trial comparing the accuracyof direct versus indirect bonding placement. JOrthod 2004;31 2):132-7.

7. Koo Be, Chung e, Vanarsdall RL. Comparison ofthe accuracy of bracket placement between directand indirect bonding techniques. Am J OrthodDentofac Orthop. 1999;116:346-51.

8. Sachdeva R. Personal communication, 2001.9. Bowman SJ Carano A. Short-term, intensive use

of the tooth positioner in case finishing . J ClinOrthod 2002;36:216-9.10. Bowman SJ. Fine-tuning case completion with the

new ProFlex po sitioner. AOAppliances , etc.2003;7{1 ):1-2.11. Mclaughlin RP, Bennett JC Trevisi HJ.Systematized orthodontic treatment mechanics

Mosby, S1. Loui s, MO, 2001.12. M cNamara JA Jr., Brudon WL. Orthodontics andentofacial orthopedics Needham Pr ess, Ann

Arbor, MI , 2001.13. Gianelly T. Bidimensional technique: Theory an

practice. GAC International , Islandia, NY, 2000.


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14. Sirirungrojying S, Saito K, Hayakawa T, Kasai K.Efficacy of using self-etching primer with a 4-META/MMA- TB B resi n cement in bond ingorthodontic brackets to human enamel and effectof saliva contamination on shear bond strength.Angle Orthod 2004;74:251-8.

15. Swartz ML. Orthodont ic Bonding. Pract Rev OrthodSelect 2004;16 2)1-4.

16. Swartz ML. Treatment efficiency. Summary byOwen Nichols. Pac Coast Soc Orthod 2004;Spring:32-34.

17. Korn M. Saving time with the orange box bondingsystem. Am Orthod. Good Practice 2002;3 1 ):4.

18. Bowman SJ Carano A. The Butterfly system. JClinOrthod 2004;38:274-287.

19. Bowman SJ Addressing concerns for finished cases:The development of the Butterfly bracket system.Part I. Interview by Ashok Karad . J Ind Orthod Soc2003;36:73-75.

20. Bowman SJ Maston PRo Infection control for curinglights. JClin Orthod 2000;34:484-486.

21. Anderson AM, Kao E, Gladwin M, Benli 0, NganP. The effects of argon laser irradiation on enameldecalcification: An n v vo study. Am J OrthodOentofac Orthop 2002;122:251-9.

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22. Noel , L, Rabellato 1 Sheats RD. The effect of argonlaser irradiation on demineralization resistance ofhuman enamel adjacent to orthodontic brackets:an n v tro study. Angle Orthod. 73:249-258,2003.23 Vivaldi-Rodrigues G, Oemito CF, Bowman , S1Ramos, AL. The effectiveness of a fluoride varnishin preventing the development of white spotlesions. World J Orthod. n press.

24. Bowman SJ. Scar tactic: Fluoride varnishes fightdecalcification stains in orthodontic patients.Orthod Prod 2002;March:32-5.

25. Bowman SJ. Use of a fluoride varnish to reducedecalcification. J Clin Orthod 2000;34:377-9.

26. Casko JS, Vaden JL, Kokich VG, Oamone J JamesRO, Cangialosi T1, Riolo ML, Owens SE Jr, BillsED . Objective grading system for dental casts andpanoramic radiographs . American Board ofOrthodontics. Am J Orthod Oentofacial Orthop.1998;114 5):589-99.

27. Richmond S, Shaw WC, O Brien KO, BuchananIB, Jones R, Stephens CD, Roberts CT, Andrews M.The development of the PAR Index Peer AssessmentRating): Reliability and validity. Eur J Orthod.1992;14 2): 125-39.

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Orthodontic Bonding; A Direct Approach

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