Bowman

CLINICAL
Orthodontic Bonding: A Direct Approach
s. Jay Bowman, D.MD. , M.S.D.
Adjunct Associate Professor,
Department of Orthodontics,
Saint Loui s University, Saint Louis, MO. ,
Straightwi re instructor,
The University of Mi chi gan, 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 light-
cured 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
adhesives and their virtually limitless working time,
more precise and yet efficient direct bonding became
feasible.
Sondhi! has stated "proper bracket positioning is a
critical part of contemporary orthodontic treatment,
especially 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 gauge, positioning jig) , or computer-
assisted "tooth-targeting system" for bracket placement
and regardless if a technician, assistant , or the
orthodontist places the brackets, it is the orthodontist-
of-record that is ultimately responsibl e for that precise
positioning.
Although there appears to be no difference in shear
bond strength between brackets that are bonded direct ly
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 hairs (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 cont emporary 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 efore, any slight, but statistically significant
improvement, derived from indirect bonding accuracy
137
may, at the end of the day, ofte n be clini ca ll y
insi gni f i ca nt. It i s somewhat like pur chas ing a
component stereo system to li sten to music. You can
pu rchase the most el aborate and sophi sticated CD
player or ampl ifi er, but if you have substandard speakers
or wiring, then the end result is a less than ideal li stening
experience; at least for the discerning audiophil e. In
other words, an attenti on to detail in all aspects of
ort hodontic care, not just bracket placement, appears
a reasonable expectati on.
Consequently, the choi ce between direct or indirect
bonding appears to be more of a practice management
decision than a treatment imperative. As such, we mi ght
then evaluate these two techniques in terms of a cost/
benefit analysi s without fea r that patient care will
somehow be egregiously affected by our select ion.
Comparing the Clinical Procedures -At first glance,
the clini cal procedures for direct and indirect bonding
are distinctly different; however, they appear to have
many similariti es when compared to one another in
terms of the steps required for each:
Direct bonding - isolation, access, visuali zat ion,
adhesive appli cation, individual bracket placement,
flash-removal, and adhesive curing.
Indirect bonding - i so l at i o n, access, adhesive
appli cat ion, bracket tray placement, adhesive curing,
and flash-removal.
If li ght-cured adhesives were pre-applied to the brackets
prior to their placement on teeth, for either the indirect
or direct technique, then both met hods would benefit
from one less clini cal procedure. Otherwise, the
principal clini ca l differences between these two
techniques appear to be threefold: the mode of bracket
placement, cost, and flash-removal.
Although a dental assi stant ca n faci I it at e either
technique, direct bonding requires more chair side
minutes. Thi s appears to be, at minimum, equitably
balanced by time spent by a laboratory techni ci an
performing the spec i ali zed procedures of bracket
placement on models and transfer tray fabr icat ion for
the indirect technique. Co nsiderin g that both
techniques also use the same devices for isolat ion of
the dentition and th e sa me ad hes i ves, then the
difference in cost is directly related to materi als and
equipment required for the laboratory procedures of
the indirect technique.
138
J Ind Orthod Soc 2004; 37:137-145
Light-cured Adhesives
When using li ght-cured adhesives, the dental assistant
can initi all y place all of the brackets on the teet h. In
thi s manner, the orthodonti st's chair side time is reduced
to simpl y the fi nal positioning of those brackets. Thi s
does require a few more minut es than the indirect
placement of an entire tray filled with brackets. In
either case, the orthodontist is still responsible for the
final positioning, whether that is accompli shed on a
stone model or directly on the teeth. Consequentl y,
the ort hodonti st's time commitment appears to
equivalent for either technique, but the practitioner can
decide to spend those few minut es ei ther in t he
laboratory or chai r side with the pat ient.
A si mil ar situat ion exists for the removal of the excess
bonding adhesive that i s expressed f rom under the
bracket as it is seated onto the tooth. For the direct
technique, this f lash is removed just prior to the final
positioning of each bracket and before li ght-cure
act ivation. At thi s stage, the soft adhesive is easi Iy
removed with simply a dental scaler. In contrast,
hardened flash is removed only after curing of the
adhesive for the indirect technique. Thi s may be a
more tedious and time-consuming procedure, often
requiring the use of rotary instruments.
If the added cost of materials, commitment to the
intermediate laboratory procedures, and more difficult
flash removal appear balanced with a sli ght ly more
accu rate bracket placement, then the sel ect i on of
indirect bonding is an easy one. If, however, the
orthodontist realizes that some individualized wire-
bending, bracket repositioning, and occasional use of
a custom tooth positioner
9
,lo are on the hori zon, no matter
the bonding technique selected, then a direct approach
may be ultimately simpl er, easier to teach auxili ari es,
and more economi cal to consider. Especiall y since
patients do not all exhibit fully erupted dentitions
{wi thout c rowdin g or rot ations} and they may
i nadvert entl y II shea r-off" a few br ac kets d u ri ng
treatment, some direct bonding may be an inescapabl e
eventuality during typical orthodontic care anyway.
With that in mind, it i s not the purpose of this
communi cation to revi sit the numerous references
prov iding superb instruct ion in bracket bonding
tec hniques,ll ,12, 13 but rather, to provide some
enhancements to the already establi shed protocols for
direct bonding.
Enhancements to Direct Bonding
Isolation, Access, and Visualization
Simply stated: if you cannot clearly see the tooth, you
cannot accurately place a direct bond. Isolation of
teeth to prevent contamination is also an issue for both
direct and indirect bonding. In addition, ambient li ght
Figure 1: An operatory li ght f ilt er (SafeVu, American
Orthodonti cs, Inc., Sheboygan, WI), constru cted from
translucent "orange" ac ryli c, prevents premature
polymerization of li ght-cured bonding adhesive and yet
provides adequate li ght for accurate bracket placement. The
filter is rotated into place, over the li ght source, only when
needed.
Figure 2: An adjustable cheek expander (WYRED, Glenroe
Technologies, Inc., Bradenton, FL) produces both buccal and
distal forces for improved access to posterior teeth during
direct bonding. The terminal end of the spring steel wire can
be used as a "finger rest" to apply more retraction to the cheek
on the side where brackets are being appli ed
Bowman
Figure 3: Pre-pasting orthodontic brackets with li ght-cure
adhesives, during assistant "downtime," provides an economi cal
method of improving the efficiency of direct bonding. After
adhesive is appli ed, the bracket is placed onto a specially
treated card to prevent loss of the adhesive when the bracket
i s subsequently removed (Slippery Bond Card, American
Orthodontics, Inc., Sheboygan, WI). Cards are prepared with
brackets specifically selected for a patient's indi vidual treatment
plan. These cards are stored in a " li ght safe" that is transported
to the operatory (Safe Box, American Orthodontics, Inc.,
Sheboygan, Wi). A "work box," const ructed from "orange"
translucent acryli c, prevents polymerization of li ght-cure
adhesives by ambient li ght during the pre-pasting process
(Work Box, American Orthodontics, Inc., Sheboygan, WI )
Figure 4. Direct bonding tray includes a "sli ppery" card with
pre-pasted brackets (Slippery Bond Card , American
Orthodontics, Inc., Sheboygan, WI). An "orange" acryli c cover
over the bracket card prevents premature polymeri zation of
the adhesive (Chairside Cover, American Orthodontics, Inc.,
Sheboygan, Wi)
139
Fi gure 5 : Verti ca l ori entati on of brackets i s the most
problemat ic issue when di rect bonding. A Boone gauge or
some derivative is often used to measure the positi on of the
edgewise slot from the incisal edge or cusp of the tooth
Figure 6: Alternat ives for vert ical bracket orientat ion: 1) a
verti cal slot gauge or disposable measuring "sti ck" (clamped
into a needl e holder) is used to measure the i ncisal edge ofthe
bracket to the incisal edge or cusp of the toot h. 2) a di sposable
measuring tape, also used to measure the bracket edge to the
incisal edge or cusp. Both devices are placed di rect ly on the
facial surface of the tooth to reduce the rotational errors inherent
w ith Boo ne-t ype gauges (B racket gauges, Gl enroe
Technologies, Brandenton, FL; Butterfly Bracket System,
Ameri can Orthodonti cs, Inc. , Sheboygan, WI)
and operatory li ghts may premat urely reduce worki ng
time when li ght-cured adhesives are used. Therefore,
some simpl e improvements in the clini cal equi pment
involved may signifi cantl y enhance di rect bonding.
140
J Ind Orthod Soc 2004; 37: 137- 145
Figure 7: A f il ter " l oll ypop" t o prevent premature
polymeri zation of l ight-cure adhesive from ambient li ght is
held over the brackets immediately after thei r i ni tial placement.
Thi s device i s removed when the orthodontist adjusts the
fi nal bracket positions
Figure 8: App ly ing fluori de varni sh (Durafl or, Ph ar ma-
science, Inc., Montreal, Canada) immediately after direct bond
procedures helps to reduce enamel demi nerali zat ion lesions.
A thin coat ing of varni sh is painted on the surfaces of the
teet h, adjacent to the brackets, using a mi ni ature sponge
appli cator
{

o . . ~ ~ I ~ r
\
I
Fi gure 9. A simple tray set- up for the re-appl icat ion of a
fluori de varni sh at 3-4 months intervals during orthodontics
to help reduce the potenti al for enamel "scars." Onl y tooth
brushing, isolation, and drying of the enamel are required
prior to reappli cati on
An operato ry li ght f il te r (SafeVu, Ameri ca n
Ort hodonti cs, Sheboygan, WI) (Fi gure 1) and adjustabl e
li p/c heek ret ract o r (WYRED retr act or, Gl enroe
Technologies, Bradenton, FL)( Fi gure 2) are two simpl e
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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.
Although hydrophilic adhesives, glass ionomers with
polyacrylic acid etch, and self-etch primers14 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
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 18.19 needed
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
Bowman
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).
Accurate Bracketing
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.
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 bracket-
positioni 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 time-
consuming 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
halogen,20 LED, plasma li ghts, and lasers). Recently,
argon lasers have been shown to signifi cantly decrease
enamel demineralization.
2
1.22 Therefore, if the cost of
these lasers becomes affordable, they may become
more prevalent in orthodontic practice. Until that time,
the routine appli cat ion of a fluoride dental varnish
(Dur af lor, Pharmasc i ence, Montreal, Canada)
immediately after the placement of brackets, with re-
appli cation every 3-4 months during treatment, has been
demonstrated to provide 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 teet h are st ill dry {Figure
8). 25 The added minute or so of time and low cost of
this material is worthwhile, especially if it mi ght prevent
or at least diminish the prevalent and unaestheti c
dilemma of enamel scars. Periodi c re-applicat ion of
varnish only requires simple tooth brushing and isolation.
For that reason, it can be easily incorporated into routine
orthodontic adjustment visits (Figure 9).
Direct or Indirect: Is That Really the
Question?
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
J Ind Ort hod Soc 2004; 37:1 37-1 45
*** Dur af lor fluoride varnish from Pharmascience
Laboratori es, Inc., 10 Orchard Pl ace, Tenafly, NJ 07670
is available from most dental suppli ers.
Commu n i cations
S. Jay Bowman
1314 West Milham Ave.
Portage, MI 49024
e-mai l: drjwyred@aol. com
References
1. Sondhi A. The impli cations of bracket selecti on
and bracket pl acement on finishing details. Sem
Orthod 2003;9:155-64.
2. Yi GK, Dunn WJ, Taloumis LJ. Shear bond strength
comparison between direct and indirect bonded
orthodontic brackets. Am J Orthod Dentofac Orthop
2003;124:577-81.
3. Sondhi A. Effici ent and effective indi rect 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, Biaggini 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 the accuracy
of direct versus indirect bonding placement. 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 positioner. 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. McNamara 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.
14. Sirirungrojying S, Saito K, Hayakawa T, Kasai K.
Efficacy of using self-etching primer with a 4-
MET 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.
Bowman
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.
Orthod Prod 2002;March:32-5.
25. Bowman SJ. Use of a fluoride varnish to reduce
decalcification. J Clin Orthod 2000;34:377-9.
26. Casko JS, Vaden JL, Kokich VG, Oamone J, James
RO, Cangialosi T1, Riolo ML, Owens SE Jr, Bills
ED. Objective grading system for dental casts and
panoramic radiographs . American Board of
Orthodontics. Am J Orthod Oentofacial Orthop.
1998;114(5):589-99.
27. Richmond S, Shaw WC, O'Brien KO, Buchanan
IB, Jones R, Stephens CD, Roberts CT, Andrews M.
The development of the PAR I ndex (Peer Assessment
Rating): Reliability and validity. Eur J Orthod.
1992;14(2): 125-39.
145