Download Orthodontic Bonding: A Direct Approach

Bowman
CLINICAL
Orthodontic Bonding: A Direct Approach
s.
Jay Bowman, D.MD. , M .S.D.
Adju nct Assoc iate Professor,
D epartment of Orthodontics,
Saint Loui s University, Saint Louis, MO. ,
Straightwi re instru ctor,
Th e University of Mi chi ga n, Ann Arbor, MI.
Abstract
Both direct and indirect bonding techniques have associated benefits and disadvantages.
Mild improvements in bonding accuracy when using indirect bonding have been proposed
to 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 other
technique is a more of practice management decision since excellent clinical results can be
achieved with either. A comparison of the two techniques along with recommendations for
simple improvements to the direct technique are presented.
Keywords
Direct bonding, indirect bonding, light cured adhesives.
The advent of bonding adhesives for orthodontics has
been one of the most significant changes in the history
of the specialty. At the outset, the accuracy of di rect
bonding of orthodontic brackets was restricted by the
limited working time of the first generation of
composite resin adhesives. In efforts to work within
the constraints presented by the materials and to
improve the accuracy of bracket placement, indirect
bonding methods were developed. These procedures
were also especially suited for lingual orthodontics due
to significant variations in lingual dental morphology.
With the subsequent introduction of light-cured
ad hesives and their virtually limitless working time,
more precise and yet efficient direct bonding became
feas ible.
Sondhi! has stated "proper bracket positioning is a
c ritical part of co ntemporary orthodontic treatment,
espec ially if some type of pre-adjusted prescription is
utilized." This is true whether brackets are directly or
indirectly placed. Despite the use of some type of
traditional dental surveyor, intraoral measuring device
(e.g., Boone ga uge, positioning jig) , or computerassisted "tooth-targeting system" for bracket placem ent
and regardless if a technician, assistant , or the
orthodontist places the brackets, it is the orthodontistof-record that is ultimately responsibl e for that precise
positioning.
Although there appea rs to be no differe nce in shear
bond strength between brackets that are bonded directly
or indirectly,2 there does seem to be a difference of
opinion as to the level of accuracy that ca n be
achieved with each. It would seem that brackets that
are placed on dry stone models, using a precision
"measuring gauge," in the quiet and well-lit confines
of a laboratory (rather than the more turbulent oral
environment), should be more accurately positioned.
In fact, those with more than just a passing academic
interest in the indirect technique claim that their
bracket placement is, indeed, significantly more
precise. 3 . 4 . s In co ntrast, Hodge and co-workers 6
concluded that mean bracket placement errors were
similar for both directly and indirectly bonded
appliances. Similar findings were reported by Koo et
al. / however, the indirect technique did demonstrate
greater accuracy for bracket hei ght.
If, however, we are simply splitting h a irs (i.e.,
measuring fractions of millimeters in bracket position),
then perhaps we should also take into equally serious
consideration the much more substantial errors inherent
to co ntemporary orthodontic treatment: errors in
diagnosis/treatment plannin g, tolerances in
manufacturing of brackets and wires, the fact that
bracket prescriptions and bases are desi gned for the
"average" tooth, and even the limited precision of arch
wire bending during treatment. It is the accumulation
of these errors that must be eliminated duri ng treatment
in order to achieve an ideal result at the conclusion. a
Ther efo re, any slight, but statistically significant
improvement, derived from indirect bonding accuracy
137
J Ind O rth od Soc 2004; 37:137-145
may, at the e nd of the day, ofte n be c lini ca ll y
in si gni f i ca nt. It i s somew h at lik e pur c has in g a
compo nent ste reo system to li ste n to mu sic. You ca n
pu rchase the most elaborate and sop hi sticated CD
player or ampl ifi er, but if you have substanda rd spea kers
or w iring, then the end resu lt is a less than idea l li stening
experience; at least for the discerning aud iop hil e. In
othe r words, an atte nti o n to detail in all aspec ts of
orthodo ntic ca re, not ju st bracket placement, appears
a reasonable expectati o n.
Conseq uently, the choi ce between direct o r indirect
bonding appea rs to be mo re of a practice management
decision than a treatment imperative. As such, we mi ght
then eva lu ate these two techniques in terms of a cost/
benefit analysi s without fea r that patient care will
somehow be egreg iously affected by our se lect io n.
Comparing the Clinical Procedures -At first glance,
the clini ca l procedures for direct and indirect bonding
are distinctly diffe rent; howeve r, they appea r to have
many similariti es when compared to o ne anoth er in
terms of the steps req uired fo r eac h:
Direct bonding - isolation, access, visu ali zation ,
adh es ive app li cation , individu al bracket placement,
flash-removal, and ad hes ive curing.
Indirect bonding - i so l at io n, access, ad h es iv e
appli cation , bracket tray placement, adhesive curing,
and flash-removal.
If li ght-cured ad hesives were pre-applied to the brackets
prior to their placement o n teeth, fo r either the indirect
or direct technique, then both methods would benefit
from one less c lini ca l procedure. Otherwise, th e
principal c lini ca l differences between these tw o
techniques appea r to be threefold: the mode of bracket
placement, cost, and flash-removal.
Although a dental ass i sta nt ca n faci I it at e e ith er
technique, direct bonding requires more chair side
minutes. Thi s appea rs to be, at minimum , eq uitab ly
balanced by time spent by a labo rato ry tech ni c ian
perfo rmin g th e spec i ali zed procedures of bracket
placement on mode ls and transfe r tray fabr icatio n fo r
the indirec t technique. Co nsid e rin g that both
techniques also use the same devices for iso lat io n of
the dentition and th e sa m e ad hes i ves, then the
difference in cost is directly related to mate ri als and
eq uipment required for the labo ratory procedures of
the indirect techniqu e.
138
Light-cured Adhesives
Wh en using li ght-cured ad hes ives, the dental ass ista nt
ca n initi all y place all of th e brackets o n the teeth. In
thi s manner, the orth odonti st's chair side time is reduced
to simpl y th e fi nal positioning of those brackets. Thi s
does require a few mo re minutes th an the indirect
placement of an entire tray filled w ith brackets. In
either case, the orthodontist is still responsib le for the
fin al positioning, w heth er that is accompli shed on a
sto ne model o r directly o n the teeth. Conseq uentl y,
the ort hodo nti st's time co mmitm e n t appears to
equ iva lent for either technique, but the practitioner ca n
decide to spe nd those few minut es ei ther in t he
labo rato ry o r chai r side with the patient.
A simil ar situ at io n ex ists for the remova l of the excess
bonding ad hes ive that is ex pressed f ro m under the
bracket as it is seated o nto th e tooth. For th e direct
technique, this flash is removed just prior to the final
positioning of eac h brac ket and befo re li ght-cure
activation. At thi s stage, the soft ad hesive is easi Iy
removed with simply a dental sca ler. In co ntrast,
hard ened flash is removed only afte r curing of the
ad hes ive for the indirect technique. Thi s may be a
more tedious and time-co nsumin g procedure, often
req uiring th e use of rotary instruments.
If the add ed cost of materials , co mmitm ent to th e
intermed iate laboratory procedures, and more difficult
flash removal appea r balanced with a sli ghtly mo re
accu rate bracket placement, then the se lect io n of
indirect bonding is an easy one. If, however, th e
o rthodontist realizes that some individu alized wirebending, bracket repositioning, and occasio nal use of
a custom tooth positioner9,loare on the horizon, no matter
the bonding tec hniqu e se lected, then a direct approac h
may be ultimately simpl er, easier to teach auxili ari es,
and mo re eco nomi ca l to co nsider. Especia ll y sin ce
patients do not all ex hibit fully erupted dentitions
{w i thout c rowdin g or rot ations} and they m ay
i nadv e rt e ntl y sh ea r-off" a few br ac kets d u ri ng
treatment, some direct bonding may be an inescapabl e
eventu ality during typical orthodontic ca re anyway.
II
With that in mind, it i s no t the purpose of this
co mmuni ca tion to rev isit th e num erous refe rences
prov idin g sup erb instru ct ion in bracket bonding
tec hniqu es,ll ,12, 13 but rather, to provide so m e
enhancements to the already estab li shed protocols for
direct bonding.
Bowman
Enhancements to Direct Bonding
Isolation, Access, and Visualization
Simp ly stated: if you cannot clearly see the tooth , you
ca nnot accurately place a direct bond. Isolation of
teeth to prevent co ntamination is also an issue for both
direct and indirect bonding. In addition, ambient light
Figure 1: An ope ratory li ght f ilte r (SafeVu, American
O rth odo nti cs, In c., Sheboygan , WI), co nstru cted from
translucent "o range" ac ryli c, prevents premature
polymerization of li ght-cured bo ndin g ad hes ive and yet
provides adeq uate li ght for accu rate bracket placement. Th e
filter is rotated into place, over the li ght source, o nly when
needed.
Figure 3: Pre-pasting orthodontic brackets w ith li ght-cure
adhesives, during assistant "downtime," provides an economi ca l
method of improving the efficiency of direct bonding. After
ad hesive is appli ed, the bracket is placed o nto a specially
treated ca rd to preve nt loss of the adhesive when the bracket
is subseq uently removed (Slippery Bond Ca rd , American
Orthodontics, Inc., Sheboygan, WI). Cards are prepared with
brackets spec ifically selected for a patient's individual treatment
plan . These ca rd s are sto red in a " li ght safe" th at is transported
to the ope ratory (Safe Box, American Orthodontics, Inc.,
Sheboygan, Wi). A "work box," constru cted from "orange"
translucent ac ryli c, prevents polymerization of li ght-cure
adhesives by ambient li ght during the pre-pasting process
(Work Box, American Orthodo ntics, Inc., Sheboygan, WI )
Figure 2: An adjustable cheek expa nder (WYRED, Glenroe
Tec hno logies, Inc., Bradenton, FL) prod uces both buccal and
distal forces for improved access to posterior teeth durin g
direct bonding. The terminal end of the spring stee l wire ca n
be used as a "finger rest" to app ly mo re retraction to th e cheek
on the side where brackets are being appli ed
Figure 4. Direct bonding tray includes a "sli ppery" ca rd with
pre-pasted brackets (Slipp e ry Bond Card , American
Orthodontics, Inc., Sheboygan, WI). An "orange" acry lic cover
over the bracket ca rd preve nts premature polymeri zation of
the adhesive (Chairside Cover, American Orthodontics, Inc.,
Sheboygan, Wi)
139
J Ind Orthod Soc 2004; 37: 137- 145
Fi gur e 5 : Verti ca l o ri enta ti o n of brackets i s th e mo st
problemat ic issue w hen d irect bo nd ing. A Boone gauge or
so me derivative is ofte n used to measure the pos iti o n of th e
edgew ise slot fro m the in cisa l edge o r cusp of th e tooth
Figure 7: A f il ter " l o ll ypop" to prevent p remature
po lymeri zatio n of light-cure ad hesive from amb ient li ght is
held over the brackets immed iately after their ini tial placement.
Thi s dev ice is removed w hen th e orthodo ntist adju sts th e
fi nal bracket pos itio ns
Figure 8 : App ly in g flu o ri de va rni sh (Duraflor, Ph ar m asc ience, Inc., Montrea l, Ca nada) immed iate ly after d irect bo nd
procedu res helps to reduce enamel dem inerali zat io n les io ns.
A thin coat ing of va rni sh is pa in ted o n the surfaces of the
teet h, ad jacent to th e brac kets, usin g a mi ni ature spo nge
app li cato r
{ •
I
o..' ~~I~ r ·
\
Figure 6: Alternat ives for vert ica l brac ket orientat io n: 1) a
ve rti ca l slot gauge or disposab le measu rin g "sti ck" (cla mped
into a needl e ho lder) is used to measure the incisa l edge ofthe
brac ket to the incisa l edge or cusp of the toot h. 2) a di sposable
measuring tape, also used to measure the bracket edge to the
in cisa l edge or cusp. Both devices are placed d irect ly on the
facia l surface of the tooth to red uce the rotatio nal errors inherent
w ith Boo ne-t ype gauges (B racke t ga uges, G le nr oe
Tec hn o log ies, Bra ndento n, FL; Butte rfly Brac ket System,
Ame ri ca n Orthodo nti cs, Inc., Sheboygan, WI)
Fi gure 9. A simp le tray set- up fo r the re-app licatio n of a
flu o ri de va rni sh at 3-4 mo nth s in te rva ls durin g o rthodontics
to help red uce the potenti al fo r ename l " sca rs." O nl y tooth
brushin g, iso lation, and drying of th e enamel are required
prior to rea ppli cati o n
and operatory li ghts may prematurely reduce working
time w hen li ght-cured adhesives are used. Therefo re,
some simpl e improvements in th e clini ca l equi pment
invo lved may signifi ca ntl y enhance d irect bo nd ing.
A n ope rato ry li ght f il te r (SafeVu , A m e ri ca n
O rthodonti cs, Sheboyga n, WI) (Fi gure 1) and adju stabl e
li p/c h ee k ret rac t o r (WYRED re tr ac t or, G l enroe
Technologies, Bradento n, FL)( Fi gure 2) are two simpl e
140
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Bowman
devices that were designed to improve this situation.
The light filter is constructed of translucent " orange"
acrylic and is placed directly in front of operatory lights
to filter the light frequencies that would prematurely
polymerize light-cured adhesives, while still providing
adequate illumination for accurate bonding.
bracket cards are then stored in a " light safe" storage
box along with cards for other patients to be bracketed
that week (Storage Box, American Orthodontics, Inc.,
Sheboygan, WI) (Figure 4).
Although hydrophilic adhesives, glass ionomers with
polyacrylic acid etch, and self-etch primers 14 have
gained popularity in recent years, they are not without
their own inherent limitations. For example, Swartz 15
has stated, "the preponderance of the studies
investigating these materials with and without
intentional water or saliva contamination suggests that
they do not compensate for poor bonding procedure or
saliva contamination." In other words, placing resin
sealant or primer onto etched enamel prior to salivary
pellicle formation is criti cal whether using a direct or
indirect approach with any adhesive. 16
The vertical position of brackets is the most problematic
aspect of direct bonding. In comparison, mesial-distal
positioning and long-axis orientation have been
reported to be just as accurate as found with indirect
bonding. 7 Consequently, some type of measuring device
would seem to be a prerequiste to precise positioning
of brackets with the direct technique.
A simple, yet adjustable, cheek expander produces not
only lateral forces but also distal retraction of the lips
to increase visibility and access to the posterior buccal
segments. The force of expansion produced by the steel
spring wire of the device can be adjusted and the
terminal wire portion is used as a finger rest to improve
retraction on only the side of the patient where a bracket
is being directly applied.
Pre-coating Brackets
The introduction of light-cured adhesives, featuring
increased working times, immediately improved the
accuracy of direct bond placement. In fact, a dental
assistant can place these adhesives on all of the brackets
to be used for a particular patient, hours or days before
their appointment. In this manner, the chair side time
required for each patient is reduced . A " word box,"
constructed using "orange" light filter plastic, prevents
ambient light from prematurely curing the adhesive as
it is applied on each bracket (Work Box, American
Orthodontics, Inc., Sheboygan, WI) {Figure 3). 17
An assistant selects only the specific brackets 18.19needed
for a particular patient's treatment plan before applying
the adhesive (e.g. premolar brackets are not pre-pasted
if these teeth are to be extracted). The pre-pasted
brackets are then placed on a specially treated card
(Slippery Bond Card , American Orthodontics, Inc.,
Sheboygan, WI) to prevent adhesive dislodgement from
the bracket base when the appliances are later removed
from the card during direct bonding. The individual
Accurate Bracketing
The typical device used to measure vertical bracket
position is the Boone gauge or some derivation thereof
(Bracket Height Gauge, Glenroe Technologies,
Bradenton , FL) (Figure 5). In general, these gauges are
to be placed at a right angle to the labial surface of the
tooth in the anterior region and parallel to the occlusal
plane in the posterior. Unfortunately, undesired
deviations in bracket position are possible if the device
is not angulated properly. An alternative is to measure
along the facial surface of the tooth from the incisal
edge of the bracket, instead of the slot, to the incisal
edge or cusp (r(Figure 6). In this manner, rotational
errors are minimized; however, a different bracketpositioni ng chart for your bracket prescription wi II need
to be created. 11
End Game: Flash Removal, Curing, and
Fluoride Varnish
An "orange" acrylic filter can be held over the seated
brackets to prevent premature polymerization from
ambient light until the orthodontist performs final
positioning (Mouth Shield, American Orthodontics, Inc.,
Sheboygan, WI) (Figure 7). Excess bonding material or
"flash " is easily removed during final bracket
positioning and prior to polymerization of the adhesive.
A simple dental scaler hand instrument is placed in the
bracket slot to orient it on the tooth surface and serves
double duty to remove the expressed adhesive around
the bond margins. This is undoubtedly less timeconsuming and potential more comfortable for the
patient than using a rotary instrument to remove
hardened adhesive, as required by the indirect
technique.
There are a number of options available for initiating
the polymerization of light-cured adhesives (e.g.
143
J Ind Orthod Soc 2004; 3 7:1 37-1 45
halogen,20 LED, plasma lights, and lasers). Recently,
argo n lase rs have been shown to signifi ca ntly decrease
enamel demineralization. 21.22 Th erefore, if th e cost of
these lase rs becomes affordable, they may become
more prevalent in orthodontic practice. Until th at time,
the routin e app li cat io n of a fluoride dental varnish
(Dur af lor, Pharm asc i e nce , Montreal, Canada )
immed iately after the placement of brackets, with reapp lication every 3-4 months during treatment, has been
demo nstrated to provid e some reduction of enamel
demi neral ization. 23,24
A thin coating of varnish is painted on the exposed
enamel of the facial surface, immediately after li ght
curing of brackets and while the teeth are still dry {Figure
8). 25 The added minute or so of time and low cost of
this material is worthwhile, especia lly if it mi ght preve nt
or at least diminish th e prevalent and unaesth eti c
dilemma of enamel scars. Periodi c re-application of
varnish only requires simple tooth brushing and isolation.
For th at reason, it can be easily incorporated into routine
orthodontic adjustment visits (Figure 9).
Direct or Indirect:
Question?
Is That Really the
Both direct and indirect methods of orthodontic bracket
placement can produce accurate and favorable results.
Some difference in procedures and costs are the major
determinants in selecting one method over the other.
Objective self-assessment of finished cases (e.g., ABO
Discrepancy Index,26 PAR Index 27 ) and/or peer-reviewed
evaluations (e.g., American Board of Orthodontics or
Angle Society examination , study clubs, case
presentations), combined with an attention to detail in
all aspects of orthodontic care, seem to be just as
important electives. Their utilization may help to avoid
stagnation in practice and repetition of the same errors,
while simultaneously optimizing improvements in
finished results for orthodontic patients. In other words,
the only way to assess the accuracy of your finished
cases, including your chosen bonding technique, is to
measure the outcomes and then fine-tune your treatment
procedures as a result.
*Orange box system, SafeVu li ght filter, and Butterfly
System are available from American Orthodontics, Inc.,
1714 Cambridge Ave. , Sheboygan, WI. 53082.
**WYRED cheek retractor and bracket position gauges
are available from Glenroe Technologies, 1912 44th Ave.
East, Bradenton, FL 34203.
144
*** D ur af lor fluorid e varnish from Pharmascience
Laborato ri es, In c., 10 Orchard Pl ace, Tenafly, NJ 07670
is ava ilable from most dental suppli ers.
Commu n i cations
S. Ja y Bowman
1314 West Milham Ave.
Portage, MI 49024
e-mai l: drjwyred@aol. com
Re ferences
1.
Sondhi A. The impli cations of bracket se lecti o n
and bracket pl acement on finishing details. Sem
Orthod 2003;9:155-64.
2. Yi GK, Dunn WJ, Taloumis LJ. Shear bond strength
comparison betwee n direct and indirect bonded
orthodontic brackets. Am J Orthod Dentofac Orthop
2003;124:577-81.
3. Sondhi A. Effici ent and effective ind irect bonding.
Am J Orthod Dentofac Orthop 115:352-9.
4. Machata B. Indirect bonding: Custom base - A
vehicle for change. Am Orthod. Good Practi ce
2003;4{1 ):5-7.
5. Melsen B, Biagg ini P. The Ray Set: A new
technique for precise indirect bonding. J Clin Ortho
2002;36:648-54.
6. Hodge TM, Dhopatkar AA, Rock WP, Spary DJ. A
randomized clinical trial comparing th e accuracy
of direct versus indirect bonding pla ce ment. J
Orthod 2004;31 (2):132-7.
7. Koo Be, Chung e, Vanarsdall RL. Comparison of
the accuracy of bracket placement between direct
and indirect bonding techniques. Am J Orthod
Dentofac 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 Clin
Orthod 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 and
dentofacial orthopedics, Needham Press, Ann
Arbor, MI , 2001.
13. Gianelly T. Bidimensional technique: Theory and
practice. GAC International , Islandia, NY, 2000.
Bowman
14. Sirirungrojying S, Saito K, Hayakawa T, Kasai K.
Efficacy of using self-etching primer with a 4MET A/MMA- TB B resi n cement in bond i ng
orthodontic brackets to human enamel and effect
of saliva contamination on shear bond strength.
Angle Orthod 2004;74:251-8.
15. Swartz ML. Orthodontic Bondi ng. Pract Rev Orthod
Select 2004;16(2)1-4.
16. Swartz ML. Treatment efficiency. Summary by
Owen Nichols. Pac Coast Soc Orthod 2004;Spring:
32-34.
17. Korn M. Saving time with the orange box bonding
system. Am Orthod. Good Practice 2002;3(1 ):4.
18. Bowman SJ, Carano A. The Butterfly system. J Clin
Orthod 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 Soc
2003;36:73-75.
20. Bowman SJ, Maston PRo Infection control for curing
lights. J Clin Orthod 2000;34:484-486.
21. Anderson AM, Kao E, Gladwin M, Benli 0, Ngan
P. The effects of argon laser irradiation on enamel
decalcification: An in vivo study. Am J Orthod
Oentofac Orthop 2002;122:251-9.
22. Noel , L, Rabellato 1, Sheats RD. The effect of argon
laser irradiation on demineralization resistance of
human enamel adjacent to orthodontic brackets:
an in vitro study. Angle Orthod. 73:249-258,2003.
23. Vivaldi-Rodrigues G, Oemito CF, Bowman , S1,
Ramos, AL. The effectiveness of a fluoride varnish
in preventing the development of white spot
lesions. World J Orthod. In press.
24. Bowman SJ. Scar tactic: Fluoride varnishes fight
decalcification stains in orthodontic patients.
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