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10.5005/jp-journals-10021-1107
CLINICAL INNOVATION
Gum and Gun: A New Indirect Bonding Technique
Gum and Gun: A New Indirect
Bonding Technique
1
Kaladhar Reddy Aileni, 2Madhukar Reddy Rachala, 3Vankare Mallikarjun
4
SBV Ramana Reddy
ABSTRACT
Bonding of brackets has changed the practice of orthodontics and has become a routine clinical procedure in a remarkably short time.
Modification of technical devices, sealants, attachments and procedure are continuing. Several methods and techniques have been introduced
by recent advances in indirect bonding techniques which have made clinician to do a more expensive laboratory work. A new method which
is more simplified and employed in our department with few expenses to invest has been followed with application of Erkogum (transparent
blocking wax) as adhesive and glue gun material as transfer tray with minimal efforts and time duration to obtain a precise indirect bonding
technique. Our trails have made it more effective and efficiently manageable to obtain a desired bonding of attachments and ease to the
patient.
Keywords: Indirect bonding, Erkogum wax, Glue gun material, Transfer tray.
How to cite this article: Aileni KR, Rachala MR, Mallikarjun V, Reddy SBVR. Gum and Gun: A New Indirect Bonding Technique. J Ind Orthod
Soc 2012;46(4):287-291.
INTRODUCTION
Bonding of brackets has revolutionized the practice of
orthodontics and has become an integral part of clinical
procedure in a remarkably short period of time. Compared
with direct bonding technique, indirect bonding is more precise
in bracket positioning, decreases the chairside time and
patient’s discomfort.1-4 Indirect bonding is a technique in
which orthodontic brackets and other attachments are
transferred from dental casts and bonded onto the dentition
using a transfer device. Silverman and Cohen5,6 in 1972, first
introduced the concept of indirect bonding. Several methods
and techniques have been evolved over the years with recent
advances in indirect bonding techniques, which have mainly
differed either in adhesive used to attach brackets to casts7-14
or in the transfer tray material.10-19
A new method which is more simplified and routinely
employed in our department with few expenses to invest has
been followed with application of Erkogum (transparent
blocking wax) as adhesive and glue gun material as transfer
tray with minimal efforts and time duration to obtain a precise
indirect bonding technique (Figs 1 and 2).
1
Erkogum, a block-out wax material, available in transparent
and colored form is composed of hydrocarbons and titanium
dioxide. It is generally used for the protection of residual teeth
and for blocking out undercuts in denture preparation. This
material can be stored indefinitely at room temperature in
closed containers. Ignition temperature of 180°C helps it to
withstand high temperature of molten glue gun material and
is completely reusable. Glue gun is a molten polymer of
ethylene vinyl acetate. It is Food and Drug Administration
(FDA) approved as noncarcinogenic, nontoxic and
dimensionally stable in its solid form.11
PROCEDURES
1. Accurate impressions are made with alginate impression
material and working casts are poured with dental stone.
2. Laboratory procedure involves initially drawing the
reference lines with the help of gauges for determining
the desired bracket position (Fig. 3). Erkogum block-out
Professor and Head, 2Reader, 3Senior Lecturer, 4Professor
1-4
Department of Orthodontics, SVS Institute of Dental Sciences
Mahbubnagar, Andhra Pradesh, India
Corresponding Author: Madhukar Reddy Rachala, Reader, Department
of Orthodontics, SVS Institute of Dental Sciences, Mahbubnagar, Andhra
Pradesh, India, e-mail: [email protected]
Received on: 22/11/11
Accepted after Revision: 12/12/11
Fig. 1: Erkogum, a block-out wax material
The Journal of Indian Orthodontic Society, October-December 2012;46(4):287-291
287
Kaladhar Reddy Aileni et al
Fig. 2: Hot gun glue for preparation of transfer tray
3.
4.
5.
6.
7.
8.
9.
10.
wax can be kneaded to a sticky dough consistency, which
aids in positioning the brackets on the predetermined
position marked on the working casts (Figs 4 and 5). The
orthodontist, when reviewing the bracket positions later,
can easily reposition any bracket with the use of same
Erkogum material. The same Erkogum material can be used
to relieve the undercut areas and block the bracket slots
(Fig. 6).
Separating medium is applied on the dentition, covering the
entire crown and adjacent gingival areas (Fig. 7).
Molten glue gun material is flowed over the incisal and
occlusal wings of the bracket and material extended over
the palatal surfaces of dentition on the working cast (Fig. 8).
The fabricated tray is then placed in water for setting of
hot tray material and later the excess material is removed
with bard parker blade (Fig. 9).
The glue gun tray has the Erkogum adhesive at its bracket
base which can be easily removed as flakes with the help of
explorer and transfer tray with clear bracket bases are ready
for use (Figs 10 and 11).
The clinical procedure includes preparation of the patient
for the bonding with proper isolation and acid-etching
(Fig. 12).
Fabrication of either single tray for entire arch or sectional
trays depends on the degree of isolation of teeth, amount
of crowding and imbrications of the teeth. While placing
the tray, it is important to support the occlusal and labial
surface of teeth to avoid any displacement (Fig. 13).
Curing of the light cure material is done initially from the
gingival aspect followed by occlusal aspects of the brackets
(Fig. 14).
After curing, the tray can be teased out easily with minimal
effort from distal aspect, thereby completing the indirect
bonding procedure (Figs 15 and 16).
Fig. 3: Reference lines drawn on working casts
Fig. 4: Bracket base with Erkogum adhesive
Fig. 5: Brackets positioned on working casts
MATERIALS AND METHODS
To evaluate the efficacy of our indirect bonding method (gum
and gun), a study was undertaken to assess the shear bond
strength of orthodontic brackets bonded with this method of
indirect bonding. The study was conducted to compare the
shear bond strength of brackets bonded with indirect bonding
288
Fig. 6: Erkogum wax used to block the bracket slots
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Gum and Gun: A New Indirect Bonding Technique
Fig. 7: Application of separation medium on dentition
Fig. 11: Transfer tray with clear bracket bases
Fig. 8: Glue gun used to prepare the transfer tray
Fig. 12: Preparation of dentition for bonding
Fig. 9: Excess tray material removed with BP blade
Fig. 13: Transfer tray seated properly in patient’s mouth
Fig. 10: Adhesive removed from bracket bases with explorer
Fig. 14: Brackets cured with light curing unit
The Journal of Indian Orthodontic Society, October-December 2012;46(4):287-291
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Kaladhar Reddy Aileni et al
Fig. 15: Removal of transfer tray
Fig. 18: Mean shear bond strength (in MPa)
Fig. 16: Final appearance after indirect bonding
Fig. 17: Universal testing machine AGS-10k NG (SHIMADZU); testing
machine—upper component with wire and lower component providing
attachment to the sample (acrylic block)
to that of direct bonding. Sixty noncarious human premolars
extracted for the orthodontic indications were collected over
2 months period and stored in 70% ethyl alcohol. The samples
were randomly divided into two groups of 30 each. In group
1, all the teeth were bonded with conventional direct bonding
method which involves, conditioning the buccal surfaces of
the teeth for 20 seconds with 37% phosphoric acid gel, rising
with a spray of water for 10 seconds and drying with oil free
air for 10 seconds, then bonded with Transbond XT adhesive
and cured for 30 seconds using LED curing unit (LEDition-
Ivoclar). All the teeth were bonded with 0.022" × 0.028" SS
brackets of MBT prescription (American Orthodontics). In group
2, all the teeth were arranged into three arch forms each
containing 10 teeth, in order to simulate the patient’s arch form.
In this group, the teeth were bonded with indirect bonding using
the Erkogum as adhesive to attach the brackets on the working
cast and glue gun material for transfer tray to bond on the
dentition. The same bonding protocol as that of group 1 was
followed in this indirect bonding procedure also. After bonding,
all the samples were stored in distilled water at room
temperature for 24 hours and subsequently tested in a shear
force on a universal testing machine (AGS-10k NG; Shimadzu,
Japan). Specimens were secured in the lower jaw of the machine
so that the bonded bracket base was parallel to the shear force
direction and were stressed in a gingivo-occlusal direction by a
stainless steel wire from the upper jaw of the machine at a
crosshead speed of 5 mm/min (Fig. 17). The means and standard
deviations of shear bond strengths were statistically analyzed
using independent t-test (Table 1).
RESULTS
The results of our study showed shear bond strength of 9.12 ±
1.38 and 7.28 ± 1.60 MPa in direct and indirect bonding groups
respectively. Independent t-test revealed that the results were
statistically significant difference between the two groups
(Fig. 18). In 1975, Reynolds20 reported that shear bond strengths
in the range of 5.9 to 7.8 MPa were needed to sustain the normal
oral and orthodontic forces. Our results on bond strength were
comparable to studies of Hocever et al,21 Klocle et al22 and
Polat et al23 whereas significantly less than that of Yi et al,24
and Linn et al,25 but were in acceptable range of minimal
requirements. Long-term in vivo studies have to be performed
before confirming its in vitro efficiency.
Table 1: Comparison of two groups (direct and indirect bonding) with respect to
bond strength of brackets by independent t-test (*p < 0.000)
Group
Mean
Direct bonding (group 1)
Indirect bonding (group 2)
9.1247
7.2800
290
SD
1.38085
1.60902
t-value
p-value
4.765
—
0.000*
—
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Gum and Gun: A New Indirect Bonding Technique
DISCUSSION
Our results after trials with Erkogum and glue gun material
have proved to be easier way of attaching brackets to the casts
and fabrication of transfer tray for indirect bonding. Erkogum
blocking out wax is a nonhazardous highly viscous material
with pleasant odor. It is permanently kneadable, reusable material
with high melting point (>200°C). The material is insoluble in
water and recommended storage temperature is 10 to 25°C.
Longer storage of the Erkogum will lead to hardening, but the
original elasticity can be regained by kneading the material.
The technique described here has several advantages over
the procedure originally described by White.11 The major
advantage of Erkogum as an adhesive in our technique is its
indefinite working time, whereas tacky glue used in White’s
technique sets quickly and must be manipulated immediately to
properly position the bracket. The use of same Erkogum to
block the bracket slots helps to avoid the locking of slots with
glue material during transfer tray preparation thereby the tray
can be easily removed after bonding. Unlike in other techniques,
where the sectional trays are routinely used to bond in mildto-moderate crowded dentition cases, our method of indirect
bonding facilitates the use of single tray only, because the
undercuts can be blocked using Erkogum, which in turn reduces
the clinical chair side time. The Erkogum material is reusable
which can withstand high temperature without melting under
hot glue gun material. A very thin layer of material will be left on
the bracket base in the transfer tray because of its high viscous
nature. Erkogum can be easily peeled off immediately once the
hot glue tray sets, unlike the case of tacky glue where the tray
has to be kept in water for almost 2 hours to both dissolve and
remove it from bracket bases. The molten glue material as transfer
tray has been proved to be more favoring in procedure and
patient’s comfort. Curing of composite adhesive is not affected
as transfer tray is transparent enough. Fabrication of tray
incorporating only the incisal and occlusal wings of brackets
helped in direct curing of composite gingivally during bonding.
A firm hold on occlusal and labial aspect of the transfer tray is
necessary while curing to overcome the flexible nature of the
transfer tray.
CONCLUSION
Indirect bonding is considered to be useful and efficient
approach that improves the clinical efficiency of accurate bracket
positioning and decreases the chair side time. The technique
described in this article using Erkogum as an adhesive provides
an indefinite working time for precise placement of brackets on
the cast, which is the main advantage of indirect bonding
method. Success to this technique requires attention to detail
but does not require excessive complexity.
ACKNOWLEDGMENTS
The authors are thankful to Dr Rohini Kumar, Senior Scientist,
Department of Organic Coatings and Polymers, IICT,
Hyderabad, for allowing me to work on universal testing
machine. And, also thankful to Dr N Sripriya, Reader,
Department of Community and Preventive Dentistry, SVS
Institute of Dental Sciences, Mahabubnagar, for helping into
carry out the necessary statistical analysis of this study.
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