BONDING IN ORTHODONTICS

PRESENTED BY- Dr. Jasmine Pannu SUPERVISED BY- Dr. Aval Luthra

 The aim of this presentation is to

develop theoretical , practical and clinical skills. Main emphasis is on clinical aspects Topic is divided into 4 parts1) Bracket bonding 2) Debonding 3) Bonded retainers 4)Other application of bonding

Bracket bonding
Advantages when compared with conventional banding Esthetically superior Faster and simpler Less discomfort to the patient Arch length not increased by band material More precise bracket placement Improved Oral hygiene Partially erupted or fractured teeth can be bonded

 Proximal enamel reduction is possible during treatment Attachments may be bonded to artificial tooth surface Interproximal areas are accesible for composite buidups Proximal caries can be detected and treated No band spaces are present to close at end of treatment Brackets may be recycled, further reducing cost. Lingual brackets can be used when the patient rejects visible appliance

Disadvantages
A bonded bracket has weaker attachment than a cemented band Better access for cleaning does not guarantee better oral hygiene and improved gingival condition Especially if excess adhesive extends beyond bracket base Bonding is more complicated when lingual auxiliaries are required Debonding is more time consuming than banding

Poor oral hygiene

BONDING PROCEDURE
CLEANING-

remove pellicle and plaque Polishing brush

Rubber cup

Bristle brush cleans more effectively

 MOISTURE CONTROL
After the rinse, maintaining dry field is essential
Lip expander Saliva ejectors

Tongue guard with bite blocks

Salivary duct obstructors

Cotton or gauze rolls

Antisialagogues Both tablet and injectable form (banthine , probanthine, atropine sulfate etc) When indicated banthine tablet 50 mg per 100lb/45 kg body wt. In sugar free drink , 15 mins before bonding

Enamel etching
The acid etch (37% phosphoric acid) is placed on each tooth surface for ~15 seconds, then suctioned with a high speed (HS) suction and rinsed abundantly

Air dry the tooth surfaces until they appear frosty white
.

 Should the etch cover the entire facial enamel or only a small portion outside the bracket pad?
an area only slightly larger than the pad, however etching the entire facial enamel with solution is harmless-at least when a fluoride mouthrinse is used regularly.
etch

VISCOSITY -GELS OR SOLUTIONS

Which is best ???? No apparent difference exists in degree of surface irregularities after etching Both are equally effective However gels provide better control for restricting the etched area

TIME OF ETCH
15 secs is probably adequate in young permanent teeth 30-50 secs may be recommended for molars Longer period results in loss of surface structure

IS SANDBLASTING AS EFFECTIVE AS ACID ETCHING?

Sandblasting followed by acid etching produces higher bond strengths

IS PROLONGED ETCHING NECESSARY WHEN TEETH ARE PRETREATED WITH FLUORIDE?

No, when in doubt check frosty white appearance. If present , surface retention is adequate for bonding.

Sealing
A thin layer of sealant is painted over the entire etched enamel surface. Is best applied with a small foam pellet or brush with single gingivoincisal stroke Coating should be thin and even excess sealant may induce bracket drift and unnatural enamel topography when polymerised

BONDING
PROCEDURE CONSISITS OF Transfer- grip the bracket with a pair of cotton pliers or a reverse action tweezer
Using Ladmore composite instrument coat the bracket base evenly with adhesive.

Positioning - Position the bracket

as precisely as possible

THE BRACKET PLACEMENT GAUGE IS USED DIFFERENTLY IN DIFFERENT AREAS OF THE MOUTH:

In the incisor regions, the gauge is placed at 90 to the labial surface.

In the canine, premolar and molar regions, the gauge is placed parallel with the occlusal plane

Excellent bracketing relies on proper visualization of the crown, its convexity, and its long axis. Use a mouth mirror to view the crowns from the incisal/occlusal view to establish good angulation and to ascertain correct mesio-distal positioning of the bracket.

FITTING
The placement scaler is turned, and with one-point contact with the bracket, it is pushed firmly toward the tooth surface The tight fit will result in Good bond strength, Little material to remove on debonding, and Reduced slide when excess material extrudes peripherally.

REMOVAL OF EXCESS
Before the adhesive has set, excess must be removed by An explorer Scaler

After the adhesive has set, It must be removed by Oval (no. 2) / Tapered (no. 1172) TC bur

If not, it will encourage plaque accumulation , and gingival irritation

TYPES OF ADHESIVES
ACRYLIC RESINS
eg. Orthomite, Genie Based on self curing acrylics Consisits of methylmethacrylate monomer and ultrafine powder. Form linear polymers Most successful with plastic brackets

DIACRYLATE RESINS
Based on acrylic modified resin : bisGMA or Bowens resin May be polymerised also by cross linking into 3D network. Hence contributes to greater strength, lower water absorption, and less polymerization shrinkage. Strongest adhesive for metal brackets

Both types of adhesive exist in either filled or unfilled forms. adhesives with large particle fillers are recommended for extra bond strength

Several alternatives exist to chemically autopolymerizing paste-paste systems 1. No-mix adhesives- These materials (e.g., Rely aBond,System 1+)

one adhesive component is applied to the bracket base while another is applied to the dried etched tooth. As soon as it is precisely positioned, the bracket is pressed firmly into place and curing occurs, usually within 30 to 60 seconds In vitro tests have shown that liquid activators of the no-mix systems are definitely toxic allergic reactions have been reported in patients,

2. Visible-light polymerized adhesivesThese materials (e.g., Transbond) may be

cured by transmitting light through tooth structure and ceramic brackets Light-cured composites are useful in situations in which a quick set is required, such as when placing an attachment on a palatally impacted maxillary canine after surgical uncovering, with the risk for bleeding. But they are also advantageous when extra long working time is desirable Fluoride-releasing, visible light-curing adhesives are also available

GIC
Bases on reaction between polyacrylic acid and leachable aluminosilicate glass

Used primarily as luting agents and direct restorative material, with unique properties for bonding chemically to enamel and dentin, as well as to stainless steel, being able to release fluoride ions for caries protection.
More recently, the glass ionomer cements have been modified to produce dual cure or hybrid cements (e.g., Fuji Ortho LC). The resin component of these cements is strongly hydrophilic, and excess water around the bracket during placement may lead to reduction in strength Used for cementing bands because they are stronger than zinc phosphate and polycarboxylate cements, with less demineralization at the end of treatment.

Bonding to crowns and restoration

Bonding of orthodontic attachments to non enamel surfaces may now be possible The Microetcher, 50 micrometre aluminum oxide particles are commonly used as sandblasting media advantageous for bonding to different artificial tooth surfaces. Rebonding loose brackets Increasing micromechanical retention for bonded retainers , Bonding to deciduous teeth. .

The Microetcher 11 is an FDA-approved intraoral sandblaster

that is most useful for preparing microretentive surfaces in metals and other dental materials, whenever needed. The appliance consists of a container for the aluminum oxide powder, a pushbutton for fingertip control, and a movable nozzle where the abrasive particles are delivered

Bonding to porcelain
1. Isolate the working field adequately bond the actual crown separately from the other teeth.` 2 Deglaze an area slightly larger than the bracket base by sandblasting with 50 um aluminum oxide for 3 seconds.

3 Etch the porcelain with 9.6% HF acid gel for 2 minutes.

4. Carefully remove the gel with cotton roll, then rinse using high-volume suction. 5. Immediately dry with air, and bond bracket with highly filled bisGMA resin. The use of a silane is optional.

The porcelain surface is restored in a two-step procedure. Smoothening is achieved with slow-speed polishing rubber wheels, whereas Enamel-like gloss can be created by application of diamond polishing paste in rubber cups or in special designed points incorporating such paste. Etchant create microporosities on the porcelain surface that achieve mechanical interlock with composite resin

The essentials for porcelain bonding:

If using Hydrofluoric Acid

consider the use of gingival barrier protection.

Bonding to amalgam
1)

Modification of the metal surface (sandblasting, diamond bur roughening)

(2) The use of intermediate resins that improve bond strengths (e.g., All-Bond 2, Enhance, Metal Primer), and

(3) New adhesive resins that bond chemically to nonprecious as well as precious metals (e.g., 4-META resins, 10-MDP bisGMA resins).

1.

Small amalgam filling with surrounding sound enamel

1. Sandblast the amalgam alloy

for 3 seconds
S A N D B L A S T

2. Condition surrounding enamel with 37% phosphoric acid for 15 to 30 seconds. 3. Apply sealant and bond with Concise, or similar, composite resin. Make sure bonded attachment is not in occlusion with antagonists.

2. Large amalgam restoration, or amalgam only

1.

Sandblast the amalgam filling for 3 seconds.

2. Apply a uniform coat of Reliance Metal Primer and wait for 30 seconds (or use another comparable primer according to manufacturer's instruction). 3. Apply sealant and bond with Concise, or similar, composite resin. Make sure the bonded attachment is not in occlusion with antagonists

Bonding to composite restoratives

The bond strength obtained with the addition of new composite to mature composite is substantially less than the cohesive strength of the material However, brackets bonded to a fresh, roughened surface of old composite restorations appear to be clinically successful in most instances. It is probably advantageous to use an intermediate primer as well.

Lingual attachments
A drawback when bonding brackets on the labial, as compared with banding, ---is that conventional attachments for control during tooth movement (e.g., cleats, buttons, sheaths, eyelets) are not included. In selected instances such aids may be bonded to the lingual surfaces to supplement the appliance

Cleats may be needed in addition to brackets when the maxillary first molars have been distalized with headgear and the premolars follow the molar

cleats

Buttons

Sheaths

eyelets

Indirect bonding
Clinical chairtime is decreased Brackets can be more accurately positioned in the laboratory

Indirect Bonding with Silicone Transfer Trays

1. Take an impression and pour up a stone (not plaster) model. The model must be dry. It may be marked for long axis and incisal or occlusal height on each tooth. 2. Select brackets for each tooth. 3. Apply a small portion of water-soluble adhesive on each base or tooth. 4. Position the brackets on the model. Check all measurements and alignments. Reposition if needed. 5. For silicone tray fabrication, mix material according to the manufacturer's instructions. Press the putty onto the cemented brackets. Form the tray, allowing sufficient thickness for strength.

6. After the silicone putty has set, immerse the model and tray in hot water to

release the brackets from the stone. Remove any remaining adhesive under running water. 7. Trim the silicone tray and mark the midline
8.Prepare the patient's teeth as for a direct application. 9. Mix adhesive, load it in a syringe, and apply a sufficient portion to the bonding bases. 10. Seat the tray on the prepared arch and hold with firm and steady pressure for about 3 minutes. 11. Remove the tray after 10 minutes. The tray may be cut longitudinally or transversely to reduce the risk of bracket debonding when it is peeled off. 12. Complete the bonding by careful removal of excess adhesive flash. Use oval (no. 7006 and no. 2) or tapered (no. 1172 or no. 1171) TC bur to clean the area properly around each bracket.

Indirect bonding with the doublesealant technique

Adhesive pastes, rather than a temporary adhesive, are used to attach the brackets to the patient's stone model Catalyst and universal adhesive pastes are dispensed side by side on a mixing Pad Enough adhesive for one attachment is mixed and applied to the back of the bonding base. The bracket is placed on the model The excess adhesive is removed from the periphery of the base. This step is repeated until all brackets are bonded to the stone model.

 After at least 10 minutes (enough time for the bonding material to set) a placement tray is vacuum-formed for each arch Models with trays attached are placed in water until thoroughly saturated. Then trays are separated and trimmed so the gingival edge of each tray is within 2 mm of the brackets. The midline is marked with indelible ink The lingual sides of the bonding bases are painted with catalyst sealant resin (part B). The dry-etched teeth are painted with the universal sealant resin (part A). The tray is then inserted into the patient's mouth, seated, and held in place for at least 3 minutes. It is removed by peeling from the lingual toward the buccal

Rebonding
Remove the loose bracket Remaining adhesive on tooth surface is removed with TC bur Adhesive remaining on loose bracket is t/t by sandblasting until all visible bonding mat. Is removed from the base Tooth is etched with 35% phosphoric acid gel for 15-30 sec After sealing, bracket is rebonded The neighbouring brackets are religated first, and then rebonded bracket is ligated

Debonding
AIM--To remove the attachment and all the adhesive resin from the tooth Restore the surface as closely as possible to its pretreatment condition. Without inducing iatrogenic damage

Bracket removal

Squeeze technique By squeezing the bracket wings with weingart pliers Gentle technique but brackets are easily destroyed and cannot be recycled

Cut technique Debonding pliers

Technique for removing steel brackets

Still ligated in place, the brackets are gripped one by one with an 095 Orthopli bracket removing plier and lifted outwardly at a 45 angle. The indentation in the pliers fits into the gingival tie-wings for a secure grip.

This is a quick and gentle technique that leaves the brackets intact and fit for recycling, if so desired.

 The bond breaks in the adhesive bracket interface, and

The pattern of the mesh-backing is visible on the adhesive remaining on the teeth.

Technique in removing Ceramic brackets

Ceramic brackets using mechanical retention cause fewer problems in debonding than to those using chemical retention Preferred mechanical debonding is to lift the brackets off with peripheral force application, much the same as for steel brackets Most recent ceramic brackets have a mechanical lock base and a vertical slot, which will split the bracket by squeezing. Seperation is at BRACKET-ADHESIVE interface, with little risk of enamel fracture Low speed grinding of ceramic brackets with no water coolant may cause permanent damage or necrosis of pulp ; water cooling of the grinding sites is necessary Thermal debonding and Use of lasers have potential to be less traumatic and less risky for enamel damage

 Removal of residual adhesive

1. Adhesive that remains after debracketing may be removed by

Scraping with debanding or debonding pliers

Or a scaler

Fast and frequently successful on premolars , canines Risk exist of creating significant scratch marks

2 Prefered method is to use a TC bur at about 30,000 revolutions per minute

Light painting movements of the bur should be used

When all adhesive has been removed, tooth surface may be polished with pumice or a commercially prophylaxis paste in a routine manner

Charateristics of normal enamel

The most evident clinical characteristics of young teeth that have just erupted into the oral cavity are the perikymata* that run around the tooth over its entire surface

SEM appearance (scanning electronic microscopy)

IN ADULT TEETH clinical picture reflects wear and exposure to varying mechanical forcs (eg. Toothbrushing habits, abrasive food- stuffs)

Influence on enamel by different debonding instruments

By proposing an enamel surface index (ESI) with 5 scores (0 to 4) for tooth appearance and using replica SEM and stepby-step polishing, Zachrisson and Artun were able to compare different instruments commonly used in debonding procedures and rank their degrees of surface marring on young permanent teeth

1) Diamond instruments were unacceptable (score 4); even fine diamond burs produced coarse scratches and gave a deeply marred appearance 2) Medium sandpaper disks and a green rubber wheel produced similar scratches (score 3

3)Fine sandpaper disks produced several marked and some even deeper scratches and a surface appearance largely resembling that of adult teeth (score 2) 4) Plain cut and spiral fluted TC burs operated at about 25,000 rpm were the only instruments that provided the satisfactory surface appearance (score 1) 5) None of the instruments tested left the virgin tooth surface with its perikymata intact (score 0).

Enamel tearouts
Ceramic brackets using chemical retention appear to cause enamel damage more often than those using mechanical retention. This damage occurs probably because the location of the bond breakage is at the enameladhesive ratherthan at the adhesive-bracket interface The clinical implication is (1) to use brackets that have mechanical retention and debonding instruments and techniques that primarily leave all or the majority of composite on the tooth and (2) to avoid scraping away adhesive remnants with hand instruments.

Enamel cracks
Fiberoptic transillumination is needed for a proper impression of the crack The occurrence of cracks in debonded, debanded, and orthodontically untreated teeth was discussed in a study by Zachrisson, Skogan, Vertical cracks are common (in fact, more than 50% of all teeth studied had such cracks), Few horizontal and oblique cracks are observed normally The most notable cracks(i.e., those invisible under normal office illumination) are on the maxillary central incisors and canines.

If orthodontist observe cracks on teeth other than max canines and Cental incisors OR detects cracks in horizontal cracks This is an indication that the bonding and / or debonding technique used may need improvement

Bonded retainers
Advantages1.

Completely invisible from the front 2. Reduced caries risk under loose bands 3. Reduced need for long-term patient cooperation 4. Prolonged semipermanent, and even permanent, retention when conventional retainers do not provide the same degree of stability Sub divisions used are1.Mandibular canine to canine retainers 2.Direct contact splinting 3.Flexible wire retainers

 Technical procedure of bonded lingual3-3 retainer

While the orthodontic appliances remain in place, take a snap impression of the patient's teeth and pour a working model of hard stone Using the working model as a guide, bend a plain round stainless steel or gold-coated wire of 0.030- to 0.032-inch diameter with a fine, straight three-jaw or similar plier so that it precisely contacts the lingual surface of all mandibular incisors

Sandblast the ends Clean the lingual surfaces of both canines with a TC bur

 Check the position of the wire in the mouth. When optimal, fix with three or four steel ligatures around the bracket wings of the incisors Isolation of working field is necessary
With retainer wire in place, etch the lingual surfaces of the canines with the Ultraetch 35% phosphoric acid gel for 30 to 60 seconds Rinse and dry completely. Use a high-speed vacuum evacuator. Sealant is not needed on lingual surfaces

 Bond the retainer using a two-step procedure:

1.Tacking---Tack the wire to both canines with a small amount of a flowable light-cured composite resin (e.g., Revolution*) and cure for 5 to 10 seconds 2.Bulk of adhesive- Bond the retainer wire to the right and left canines, applying resin from the gingival margin to the incisal edge with a composite-placement Instrument Check with a mouth mirror to see that enough adhesive is used, and add more adhesive wherever required

 Trim along the gingival margin and contour the bulk with an oval TC bur (no. 7408) This step is mandatory Instruct the patient in proper oral hygiene and use of dental floss beneath the retainer wire and along the mesial contact areas of both canines

Flexible spiral wire retainer

Advantages
1.They may allow safe retention of treatment results when proper retention is difficult, or even impossible, with traditional removable appliances 2.They allow slight movement of all bonded teeth and segments of teeth. Apparently this is the main reason for the excellent long-term results 3.They are invisible. 4. They are neat and clean. 5. They can be placed out of occlusion in most instances. If not, there remains the possibility of hiding the wire under a slight groove in the enamel. 6. They can be used alone or in combination with removable retainers

 Toward the end of orthodontic treatment, take a snap impression and pour a working model in stone. Adapt the 0.0215-inch Penta-One steel* or goldcoated wire closely and passively to the crucial areas of the lingual surface of the teeth to be bonded. Cut the wire to the required length. Check the retainer wire in the mouth for good fit in an entirely passive state and adjust if necessary Clean the surfaces to be bonded with a TC bur and etch with Ultraetch 35% phosphoric acid gel for 30 to 60 seconds Initial tacking is done Add bulk of adhesive Use oval TC burs (no. 7006 and 7408) to obtain correct amount and contour of adhesive Instruct the patient in proper oral hygiene and use of dental floss over the contact points

Technical procedure

Indications
1 Prevention

of space reopening Median diastemas(0.0215 inch 5 stranded wire over 4 units) Spaced anterior teeth Adult periodontal conditions with the potential for postorthodontic tooth migration Accidental loss of maxillary incisors requiring the closure and retention of large anterior spaces Mandibular incisor extractions 2. Holding of individual teeth Severely rotated maxillary incisors Palatally impacted canines

Direct bonded labial retainers

Typical problems1. Inability to prevent some space reopening in closed extraction sites in adults

2. A tendency for some lingual relapse of previously palatally impacted canines 3. Space reopening when molars and premolars had been moved mesially in cases with excess space

Technical procedure

A straight piece of 0.0215-inch Penta-One wire (goldcoated or stainless steel) is cut to the desired length. After etching, the retainer wire is tacked on the teeth after both ends are dipped in the fast-setting mix of composite on a plastic spatula

After the adhesive sets, a bulk of adhesive is added.

Contour trimming of excess is done with TC burs (nos. 7408 and 7006) and interdental trimming is done with small round burs (nos. 1 or 2).

 Other applications of bonding in orthodontics

Space maintainers recommended design using round 0.032 inch SS wire

Using 6 stranded 0.032 inch spiral wire with utility wire design

Bonded single tooth replacements

The following properties were aimed at: 1. Possibility for physiologic movement of the bridge units within the periodontal tissues 2. Avoidance of direct occlusal contact on metal 3. Uncomplicated repair

4. Access to the pulp cavity and root canal in cases where endodontic treatment might be indicated

Construction and appearance of a three-wire bonded, single-tooth replacement

Acrylic tooth fitted on a plaster working model (PM) and temporarily attached with sticky wax. Two braided 0.016- X 0.022-inch wires are contoured along the gingival margin of the supporting incisors; one round (0.020) spiral wire provides additional support.

The wires are bonded to the artificial crown with cold-cure acrylic

 Acrylic tooth (AT) bonded Final result. Right central with restorative composite incisor made slightly shorter than the intact left incisor to avoid excessive load in eccentric mandibular movements

Alternative designs for single-tooth replacement with a four-wire design where two braided wires run through the pontic

Trauma fixation
Temporary fixation of several loose maxillary incisors after injury. Spiral wire bonded to five units. This procedure is simple, neat, and clean.

Composite build ups porcelain laminate veneers

The addition of composite resin or porcelain laminates to noncarious teeth during or after orthodontic treatment may be indicated on single or multiple teeth to solve tooth shapeand/or size problems. Eg peg shaped laterals, composite buidups, premolar autotransplantation Peg shaped laterals

Autotransplantation of premolar in anterior region followed by composite buildups

Conclusion
The simplicity of bonding can be misleading. Success in bonding requires- understanding of and adherence to accepted orthodontic and preventive dentistry principles. In most routine cases brackets are bonded on all teeth except maxillary first molars. Banding maxillary first molars provides a stronger attachment and availability of lingual sheaths (for transpalatal bars, elastics, headgear, etc.) The mandibular second molar is better suited for bonding than for banding because gingival emergence of the buccal surface precedes emergence of the distal surface.