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A new resin designed specifically for indirect bonding has been developed. Previous problems with indirect
bonding systems, which were partly related to the fact that resins designed for direct bonding had to be
used, have been addressed. A cohesive and complete system for fabricating bonding trays, and the indirect
bonding procedure, is presented. (Am J Orthod Dentofacial Orthop 1999;115:352-9)
It has been widely recognized for many high. Different glues have been tried over the years, but
years that accurate bracket positioning is of critical only with moderate success.
importance in the efficient application of biomechanics Heat-cured resins subsequently entered the market,
and in realizing the full potential of a preadjusted edge- but several clinicians have experienced problems with
wise appliance. The same principle that governs real bracket float while heating the resin. This is aggravated by
estate is applicable to bracket positioning—Location! the fact that the model must be heated to 350° for approx-
Location!! Location!!! imately one half hour to cure the resin (Thermacure,
Reliance Orthodontic Products). Further, ceramic brack-
BRACKET POSITIONING AND DIRECT BONDING ets could not be exposed to such heat and had to be placed
The advent of direct bonding improved the clini- separately after the metal brackets had been heat cured, a
cian’s ability to position the brackets more accurately cumbersome procedure. Current techniques for bonding
than when using bands. The introduction of light-cured tray placement use chemically cured sealants or bonding
resins like Transbond XT Light Cure Adhesive (Trans- resins. However, if a transparent tray is used, light-cured
bond, 3M/Unitek, Monrovia, Calif) further improved resin, with cure-on-demand benefits, can be used.7
the working time available to the clinician, permitting
significant latitude in positioning the brackets before the RESIN DESIGN
resin is cured. However, achieving an accurate and con- This clinician has consistently used indirect bond-
sistent bracket position on the posterior teeth continues ing in one form or another for the last 16 years. It
to present a problem because of poor access. Rebonding became clear that one of the deficiencies in the avail-
on posterior teeth isn’t any easier than bonding them the able systems is that all the resins and procedures had
first time, therefore the less bracket repositioning one originally been designed for direct bonding, and subse-
has to do on the posterior teeth, the better. On the ante- quently were just adapted for indirect bonding.
rior teeth and the premolars, the cost of repositioning For example, a desirable feature for a resin
the increasingly popular ceramic brackets is of concern. designed for direct bonding is a generous window of
This is less of an issue with indirect bonding. working time. In indirect bonding, once the tray is
placed there is clearly no use for an extended cure time.
BRACKET POSITIONING AND INDIRECT BONDING After years of innovation, laboratory testing, and clini-
Indirect bonding, in various forms, has been around cal trials, a significantly superior, efficient, and effec-
for several years.1-6 Most of these forms have been tive indirect bonding procedure has been developed
variations on the technique originally proposed by utilizing a new resin specifically designed for indirect
Thomas.1 Initially, we used candy to position the bonding. An additional benefit of this procedure is that
brackets on the teeth, and chemically cured resins to it does not require heating the models, since a custom
bond the brackets to the teeth. This generally resulted base is developed with light-cured adhesive.
in excessive flash, and clean-up was a significant prob-
lem. In addition, the laboratory time was excessively ADVANTAGES OF INDIRECT BONDING
Obviously, there are some significant advantages to
*Research is supported in part by 3M/Unitek. indirect bonding1-7:
In private practice. 1. Accurate bracket placement
Reprint requests to: Anoop Sondhi, DDS, MS, 9333 N Meridian, Suite 301, 2. Optimizing the use of doctor’s time
Indianapolis, IN 46260
Copyright © 1999 by the American Association of Orthodontists. 3. Avoiding band fitting on posterior teeth
0889-5406/99/$8.00 + 0 8/1/97643 4. Eliminating the need for separators
352
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 353
Volume 115, Number 4
A
A
B
B
C
Fig 1. Anterior (A) and occlusal (B) views of maxillary C
working models for indirect bonding. C, application of
separating medium. Fig 2. A, Placement of APC brackets on the working
model; B, lateral view of working model shows individual
bracket positions; C, models ready to be checked; mod-
els are kept in a black box to keep out ambient light.
5. Improved ability to bond posterior teeth
6. Improved patient comfort and hygiene
new resin has been developed with the help of 3M
DISADVANTAGES OF INDIRECT BONDING Unitek. This material is designed with several objectives
1. Technique sensitive in mind. The viscosity has been increased with the use of
2. Additional set of impressions needed a fine particle fumed silica filler (approximately 5%), so
3. Posterior attachments more likely to fail if that any small imperfections in the custom base crafted
patient chews ice, etc. from the light-cured adhesive, as well as any imperfec-
tions in the fit of the custom base against the enamel, will
A NEW INDIRECT BONDING MATERIAL be taken up by the filled resin. An unfilled resin, on the
Having recognized the clinician’s need for bonding other hand, would be less viscous and could cause
materials designed specifically for indirect bonding, a bracket drift. Further, the resin has a quick set time of 30
354 Sondhi American Journal of Orthodontics and Dentofacial Orthopedics
April 1999
A
Fig 3. Maxillary and mandibular indirect bonding mod-
els placed in the TRIAD chamber.
A D
E
Fig 5. A, Sectioned tray being removed from model; B,
trimmed indirect bonding trays placed in the TRIAD
B chamber for additional curing; C, occlusal view of indi-
rect bonding tray; D, tissue-side view of indirect bonding
tray clearly identifying inner soft layer and outer hard
shell; E, close view of individualized bonding pads
formed with Transbond.
A A
B B
Fig 6. A, Isolation of working area with NOLA dry-field
system; B, etched enamel surface being air dried.
A A
B B
C C
Fig 8. A, Placement of mandibular bonding tray; B, max-
illary and mandibular bonding trays in place; C, removal
of mandibular bonding tray.
have a frosty appearance and be completely des- strength is demonstrated in pounds per bracket, and a
iccated. If a frosty appearance is not apparent, total of 25 brackets were tested. Fig 10B provides more
repeat the etching process for 15 seconds. important data, since the bond strength immediately
10. Small amounts of the indirect bonding Resin A after curing is of critical importance during tray
and B liquids should be poured into the wells (Fig removal, and initial arch wire insertion. In that test, our
7A). Take care to keep liquids separate. Resin A indirect resin showed substantially greater bond
can be painted onto the tooth surface with a brush, strength than the other resins. After 1 hour, the other
and Resin B can be painted on the resin pads in resins started to catch up (Fig 10C). Eventually, the
the indirect bonding tray (Fig 7B and C) bond strength of all three materials peaked to relatively
11. If too much resin has been placed on the enamel, similar levels. However, the clinical efficacy of this
gently remove the excess with a brush. The over- resin is greatly enhanced by the higher bond strength
all method of painting the resin on the enamel when tested at the 5 minute level. Indirect bonding
and the custom bases is not unlike painting one’s with Concise Enamel Bond has a distinct disadvantage,
fingernails. of course, because of the limited working time, longer
12. Position the tray over the teeth and seat the tray with cure time, and the need to mix the resin. As has been
a hinge motion. With the fingers, apply equal pres- pointed out earlier in this article, this is because Con-
sure to the occlusal, labial, and buccal surfaces. cise Enamel Bond was developed specifically for direct
Hold for a minimum of 30 seconds. Allow 2 more bonding, and the Sondhi Indirect Adhesive has been
minutes of cure time before removing the tray (Fig developed specifically for indirect bonding.
8A). This procedure is now repeated for the oppos-
ing arch (Fig 8B). Because of the rapid set time of DISCUSSION
this adhesive, by the time the opposing tray is A new method for effective and efficient indirect
placed, removal of the first tray can begin (Fig 8C). bonding of orthodontic brackets has been presented. The
Fig 9A-D show the completed appliance placement. custom adhesive bases are easily formed with Transbond
13. Remove the tray by using a scaler to peel the tray XT on APC brackets, and the indirect bonding is accom-
from the lingual to buccal. Use extreme care plished with a new resin developed specifically for this
when removing the tray from around bracket purpose. Bond strength has proven to be excellent, and
wings. Scale the excess resin around the brackets we have used this system for the indirect bonding of
and from the interproximal contacts. Use dental complete dental arches, from second molar to second
floss to check that all contacts are open. molar, on pediatric, adult, and orthognathic cases.
14. An initial arch wire, such as an 0.016 Nitinol I gratefully acknowledge the contribution of Mr Darrell
Heat-Activated Wire can now be inserted. James of 3M/Unitek in the development of the resin reported
in this article. The assistance provided by Mr Steve Fletcher,
RESULTS
Ms Rani Stoddard, and Mr John Lamitie in the preparation of
In treating over 500 patients, our experience with this article is also gratefully acknowledged.
this indirect bonding adhesive has revealed that the
References
bonding is relatively consistent and efficient. Occa-
1. Thomas R. Indirect bonding: simplicity in action. J Clin Orthod 1979;13:93-106.
sional bond failures do occur, of course, and are usually 2. Moin K, Dogon IL. Indirect bonding of orthodontic attachments. Am J Orthod
related to contamination or improper technique. In 1977;72:261-75.
3. Simmons M. Improved laboratory procedure for indirect bonding of attachments. J
those cases, it is a simple matter to section the bonding Clin Orthod 1978;12:300-2.
tray, reapply the adhesive, and reseat the brackets. 4. Silverman E, Cohen M. A report on major improvement in the indirect bonding of
attachments. J Clin Orthod 1975;9:270-6.
Bond strength tests have also proved the efficacy of 5. Scholz R. Indirect bonding revisited. J Clin Orthod 1983;17:529-36.
this resin. The graph illustrated in Fig 10A shows that 6. Moskowitz EM, Knight LD, Sheridan JJ, Esmay T, Kruno T. A new look at indirect
bonding. J Clin Orthod 1996;5:277-81.
bond strength compares favorably with indirect bond- 7. Kasrovi P, Timmins S, Shen A. A new approach to indirect bonding using light-cure
ing using Concise Enamel Bond and Custom IQ. Bond composites. Am J Orthod Dentofacial Orthop 1997;6:652-66.