Bonding-in-Orthodontics

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CHAPTER
14
Bonding in Orthodontics
Björn U. Zachrisson, Tamer Büyükyilmaz
rthodontists now are approaching 35 years of
successful, reliable orthodontic bonding in offices
around the world. The median bond failure rate for practitioners in the United States is presently around 5%.
The only teeth that were banded routinely by a majority
of U.S. orthodontists in a recent survey were the maxillary first molars, and all molars and premolars were
banded less routinely than in the past.128 The prevailing
concepts are challenged continuously by new developments and technical improvements.
Achieving a low bond failure rate should be a highpriority objective, for replacing loose brackets is inefficient, time-consuming, and costly. Consequesntly, a
continuous search is on for higher bond strengths, better
adhesives, simpler procedures, and materials that will
bond in the presence of saliva. However, most bond failures result from inconsistencies in the bonding technique
and not because of the bonding resins, inadequate bond
strengths, or quality of the brackets being used.215 Newer
resin systems and alternative methods to bond to enamel
may be giving the false impression that one need not be
so careful with the bonding procedures as before.
The basis for the adhesion of brackets to enamel
has been enamel etching with phosphoric acid, as first
proposed by Buonocore43 in 1955. In the early 1970s a
considerable number of preliminary reports were published on different commercially available direct and
indirect bonding systems.198 The first detailed posttreatment evaluation of direct bonding over a full period of
orthodontic treatment in a large sample of patients, was
published in 1977.251 Since then, product development
in terms of adhesive resins, brackets, and technical details
has occurred at a rapid rate (Figure 14-1). In fact, the
progress has made it difficult for the practicing orthodontist to stay properly oriented.
The purpose of this chapter is to update the current
available information on bonding to natural and artificial teeth. Further developments are likely to produce
significant changes in several of the ideas, clinical suggestions, and even principles presented. Therefore the
main emphasis in this chapter is on clinical aspects.
Attempts are made to analyze important factors and
O
offer advice (based on the authors’ own clinical and
research experience and the results published by others)
to help make the bonding of attachments and retainers
efficient and trouble free.
To help organize the contents, the chapter is divided
into four parts:
1. Bracket bonding
2. Debonding
3. Bonded retainers
4. Other applications of bonding
BRACKET BONDING
The simplicity of bonding can be misleading. The
technique undoubtedly can be misused, not only by an
inexperienced clinician but also by more experienced
orthodontists who do not perform procedures with care.
Success in bonding requires understanding of and adherence to accepted orthodontic and preventive dentistry
principles.
The advantages and disadvantages of bonding versus
banding of different teeth must be weighed according
to each practitioner’s preferences, skill, and experience.
Bonding should be considered as only part of a modern
preventive package that also includes a strict oral hygiene
program,248 fluoride supplementation,44,185,249 and the
use of simple yet effective appliances (Figure 14-1). In
other words, complicated mechanics with abundant use
of coil springs and multilooped arches lends itself less
well to bonding and easily can compromise the integrity
of tooth enamel and gingival tissues around brackets on
small bonding bases.
Bonding Procedure
The steps involved in direct and indirect bracket bonding
on facial or lingual surfaces are as follows:
• Cleaning
• Enamel conditioning
• Sealing
• Bonding
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A
B
C
D
Figure 14-1
Esthetic comparison between bonded appliances. A, Stainless steel brackets. B, Ceramic brackets. C, Ceramic
and gold-coated brackets. D, Lingual bonding.
Cleaning
Cleaning of the teeth with pumice removes plaque and
the organic pellicle that normally covers all teeth.1 One
must exercise care to avoid traumatizing the gingival
margin and initiating bleeding on teeth that are not fully
erupted.
The need for conventional pumice polishing before
acid etching has been questioned.139,214However, pumice
prophylaxis does not appear to affect the bonding procedure adversely, and cleaning the tooth may be advisable to remove plaque and debris that otherwise might
remain trapped at the enamel-resin interface after bonding. Furthermore, Reisner et al.180 found more consistent
results when buccal tooth surfaces were abraded lightly
with a tungsten carbide bur (#1172) at slow speed
(25,000 rpm) than when the surfaces were pumiced for
10 seconds before acid etching.
Enamel conditioning
Moisture Control. After the rinse, salivary control
and maintenance of a dry working field is essential.
Many devices on the market accomplish this:
• Lip expanders and cheek retractors
• Saliva ejectors
• Tongue guards with bite blocks
Figure 14-2
Large Dri-Angle for restriction of saliva from the parotid
duct.
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Chapter 14 • Bonding in Orthodontics
•
•
•
•
Salivary duct obstructors (Figures 14-2 and 14-3)
Gadgets that combine several of these (Figure 14-4)
Cotton or gauze rolls
Antisialagogues
These products are being improved continually, and
the clinician must decide which ones work best. For
simultaneous molar-to-molar bonding in both arches, a
technique using lip expanders, Dri-Angles (to restrict
the flow of saliva from the parotid duct), and saliva ejectors (see Figure 14-4) works well.
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Regarding antisialagogues, tablets55 and injectable
solutions37,239 of different preparations (e.g., methantheline bromide [Banthine], propantheline bromide [ProBanthine], and atropine sulfate) are available. However,
the excellent and rapid saliva flow restriction obtainable
with propantheline bromide injections239 is no longer
advised. The Council on Dental Therapeutics of the
American Dental Association has recommended that
this drug not be injected in patients who can take the
oral form.
B
A
Figure 14-3
Working field at bonding of second molars.
A
B
Figure 14-4
A, Combined saliva ejector, tongue holder, and bite block (BB-SE) for moisture control during bracket bonding.
B, High-speed saliva evacuator with large opening is important for optimal collection of the etchant-water
rinse.
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Present experience indicates that antisialagogues
generally are not needed for most patients. When indicated, methantheline (Banthine) tablets (50 mg per 100 lb
[45 kg] body weight) in a sugar-free drink, 15 minutes
before bonding, may provide adequate results.55
Enamel Pretreatment. After the operative field has
been isolated, the conditioning solution or gel is
applied over the enamel surface for 15 to 30 seconds
(see the following discussion). When etching solutions
are used, the surface must be kept moist by repeated
applications.
At the end of the etching period the etchant is rinsed
off the teeth with abundant water spray. A high-speed
evacuator (see Figure 14-4) is strongly recommended
for increased efficiency in collecting the etchant-water
rinse and to reduce moisture contamination on teeth
and Dri-Angles. Salivary contamination of the etched
surface must not be allowed. (If contamination occurs,
rinse with the water spray or re-etch for a few seconds;
the patient must not rinse.)
Next, the teeth are dried thoroughly with a moistureand-oil-free air source to obtain the well-known dull,
frosty appearance (Figure 14-5). Teeth that do not appear
dull and frosty white should be re-etched. Cervical enamel,
because of its different morphology, usually looks somewhat different from the center and incisal portions of a
sufficiently etched tooth10 (see Figures 14-5 and 14-34).
The cervical enamel should not be re-etched in attempts
to produce a uniform appearance over the entire
enamel surface.
B
C
E
F
A
D
Figure 14-5
Acid-etch conditioning of enamel before bracket bonding. A, Frosty white appearance. B and C, Scanning
electron micrograph of an enamel surface that has been etched with 37% phosphoric acid. (In B the prism
centers have been removed preferentially, whereas in C the loss of prism peripheries demonstrates the headand-tail arrangement of the prisms.) D to F, Transverse section of an etched porous enamel surface showing
two distinct zones, the qualitative porous zone (QPZ) and the quantitative porous zone. In the latter an even
row of resin tags (T) may penetrate.
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This procedure probably reflects the general use of
acid etching in orthodontics. However, considerable discussion of and continuous debate over several aspects of
enamel pretreatment remain:
1. Should the etch cover the entire facial enamel or
only a small portion outside the bracket pad?
2. Are gels preferable to solutions?
3. What is the optimal etching time? Is it different for
young and old teeth?
4. Is sandblasting as effective as acid etching?
5. What is the preferred procedure for deciduous
teeth?
6. Is prolonged etching necessary when teeth are
pretreated with fluoride?
7. Will incorporation of fluorides in the etching
solution increase the resistance of enamel to caries
attack?
8. Is etching permissible on teeth with internal white
spots? Or is it more likely that the etchant will
open up underlying demineralized areas?
9. How much enamel is removed by etching, and
how deep are the histologic alterations? Are they
reversible? Is etching harmful?
10. Should means other than acid etching with
phosphoric acid (e.g., polyacrylic acid, maleic
acid, or self-etching primers) be preferred?
Although these questions are of considerable theoretical interest, most debate concerning acid etching
appears to be of limited clinical significance, at least as
it bears on bond strength. In other words, good bond
strength apparently depends much more on (1) avoiding
moisture contamination and (2) achieving undisturbed
setting of the bonding adhesive than on variations in
the etching procedures.
Some short answers to the foregoing questions are as
follows:
1. Although it may seem logical to etch an area only
slightly larger than the pad, clinical experience over
more than 25 years indicates that etching the entire
facial enamel with solution is harmless—at least
when a fluoride mouth rinse is used regularly.
2. No apparent difference exists in the degree of
surface irregularity after etching with an acid
solution compared with etching with an acid gel.38
Gels provide better control for restricting the etched
area but may require more thorough rinsing
afterward. The most popular enamel/dentin etchant
in general dentistry is the Ultraetch 35%
phosphoric acid blue gel (Ultradent Products,
South Jordan, Utah). This gel is dispensed by
syringe; has adequate color contrast, smooth
consistency, and almost ideal viscosity for
application and rinsing off cleanly; and provides an
even, nicely demarcated white frosted appearance.
This etchant is recommended whenever extra good
etching of enamel is desired, such as for deciduous
3.
4.
5.
6.
7.
8.
9.
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teeth, for rebonding brackets, and for bonded
retainers (see Figure 14-60, A).
Studies38,39,154, 158,235 and clinical experience indicate
that 15 to 30 seconds is probably adequate for
etching most young permanent teeth. However,
important individual variation exists in enamel
solubility between patients, between teeth, and
within the same tooth. One benefit of conventional
acid etching is that it tends to neutralize the
differences between individuals and between teeth.
Thus a phosphoric acid etch of sufficient time can
compensate for those individuals whose enamel is
more acid resistant. Attempts to use materials that
produce a minimal etch—such as glass ionomers,
hybrid resin glass ionomers, and the newer
self-etching primers—appear to result in increased
clinical bond failure rates.
Sandblasting without acid etching produces lower
bond strengths than acid etching and consistently
results in bond failures at the enamel-adhesive
interface.168,180 Sandblasting followed by acid
etching produces bond strengths comparable to or
higher than acid-etched enamel.180
A recommended procedure for conditioning
deciduous teeth is to sandblast with 50-µm
aluminum oxide for 3 seconds to remove some
outermost aprismatic enamel and then etch for
30 seconds with the Ultraetch 35% phosphoric
acid gel. The failure rate with this procedure for
the authors is less than 5%.
Clinical and laboratory experience38,39 indicates that
extra etching time is not necessary when teeth have
been pretreated with fluoride. When in doubt,
check that the enamel looks uniformly dull and
frosty white after the etch; if it does, surface
retention is adequate for bonding.
Fluoridated phosphoric acid solutions and gels
provide an overall morphologic etching effect
similar to nonfluoridated ones and give adequate
bond strength in direct-bonding procedures.46,91,149
Further studies are needed to determine their
effectiveness regarding caries protection around
brackets over a full period of orthodontic treatment.
One should exercise caution when etching over
acquired and developmental demineralizations. The
procedure is best avoided. If this is impossible, a
short etching time, the application of sealant or
primer, and the use of direct bonding with extra
attention to not having areas of adhesive deficiency
are important. The presence of voids, together with
poor hygiene, can lead to metal corrosion142 and
indelible staining of underlying developmental
white spots.58
A routine etching removes from 3 to 10 µm of
surface enamel.58,176,200,221 Another 25 µm reveals
subtle histologic alterations,45,102,199 creating the
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Figure 14-6
Fitting surface of adhesive resin after the removal of
enamel by demineralization. This surface shows an
evenly distributed row of tags. (Courtesy ML Swartz,
Encino, California.)
necessary mechanical interlocks (Figure 14-6; see
also Figure 14-5). Deeper localized dissolutions
generally cause penetration to a depth of about
100 µm or more.45,73,199 Although laboratory
studies indicate that the enamel alterations are
largely (though not completely) reversible,197,199
the overall effect of applying etchant to healthy
enamel is not detrimental. This point is
augmented by the fact that normally enamel is
from 1000 to 2000 µm thick73,267(except as it
tapers toward the cervical margin), abrasive wear
of facial enamel is normal and proceeds at a rate
of up to 2 µm per year, and facial surfaces are
self-cleaning and not prone to caries.143
10. Use of polyacrylic acid with residual sulfate is
reported142 to provide retention areas in enamel
similar to those after phosphoric acid etching with
less risk of enamel damage at debonding.
However, other researchers have found much
weaker bonds.14,32,79,177 The same is true for the
use of maleic acid.174
Sealant, primers
After the teeth are completely dry and frosty white, a thin
layer of bonding agent (sealant, primer) may be painted
over the etched enamel surface. The coating may be
thinned by a gentle air burst for 1 to 2 seconds. Bracket
placement should be started immediately after all
etched surfaces are coated.
Much confusion and uncertainty surround the use of
sealants and primers in orthodontic bonding. Research
has been devoted to determining the exact function of
the intermediate resin in the acid-etch procedure. The
findings are divergent. Some investigators conclude that
an intermediate resin is necessary to achieve proper
bond strength; some indicate that intermediate resin is
necessary to improve resistance to microleakage; others
feel intermediate resin is necessary for both reasons; still
others do not think that the intermediate resin is necessary at all.118,175,236
A particular problem in orthodontics is that the
sealant film on a facial tooth surface is so thin that
oxygen inhibition of polymerization is likely to occur
with autopolymerizing sealants. With acetone-containing
and light-polymerized sealants, nonpolymerization seems
less of a problem.
Why then should a sealant be of any value in bracket
bonding? If nothing else, sealant permits a relaxation of
moisture control because this is no longer critical after
resin coating. Sealants also provide enamel cover in areas
of adhesive voids, which is probably especially valuable
with indirect bonding. The caries protection of sealant
around the bracket base is more uncertain,58,103,236
and further studies are needed on the clinical merits of
fluoride-containing sealants.25,59 Ceen and Gwinnett59
found that light-polymerized sealants protect enamel
adjacent to brackets from dissolutions and subsurface lesions, whereas chemical-curing sealants may
polymerize poorly, exhibit drift, and have low resistance
to abrasion.58,266
Moisture-insensitive Primers. In an attempt to
reduce the bond failure rates under moisture contaminations, hydrophilic primers that can bond in wet fields
(Transbond MIP, 3M/Unitek, Monrovia, California; and
Assure, Reliance Orthodontics, Itasca, Illinois) have been
introduced as a potential solution. Laboratory studies
investigating the effect of saliva contamination on bond
strength show conflicting results.100,110,191,195,272 Although
bond strengths were significantly lower under wet conditions than in dry conditions, the hydrophilic primers
may be suitable in difficult moisture-control situations.
This may be the case in some instances of second molar
bonding and when there is risk for blood contamination on half erupted teeth and on impacted canines. For
optimal results, the moisture-insensitive primers should
be used with their respective adhesive resins.
The hydrophilic resin sealants or primers polymerize in the presence of a slight amount of water, but they
will not compensate routinely for saliva contamination. When bonding to enamel, one must place the
resin sealant or resin primer onto the prepared enamel
before the pellicle (biofilm) from the saliva. This is not
particularly difficult but is crucial to a successful
enamel bond.215
Self-Etching Primers. Combining conditioning
and priming into one step may result in improvement
in time and cost-effectiveness for clinicians and
patients, provided the clinical bond failure rates are not
increased significantly. The main feature of the singlestep etch/primer bonding systems is that no separate
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Chapter 14 • Bonding in Orthodontics
acid etching of the enamel and subsequent rinsing with
water and air spray is required; the liquid itself has a
component that conditions the enamel surface. The
active ingredient of the self-etching primers (SEPs) is a
methacrylated phosphoric acid ester that dissolves calcium from hydroxyapatite. Rather than being rinsed
away, the removed calcium forms a complex and is
incorporated into the network when the primer polymerizes. Etching and monomer penetration to the
exposed enamel rods are simultaneous, and the depth
of etch and primer penetration are identical.
Three mechanisms act to stop the etching process.
First, the acid groups attached to the monomer are
neutralized by forming a complex with calcium from
hydroxyapatite. Second, as the solvent is driven from
the primer during the airburst step, the viscosity rises,
slowing the transport of acid groups to the enamel interface. Finally, as the primer is light cured and the primer
monomers are polymerized, transport of acid groups to
the interface is stopped.62 Scanning electron microscopy
examination of the impression of SEP-treated enamel
shows different surface characteristics from acid-etched
enamel (Figure 14-7, B and C). Instead of the wellknown distinct honeycombed structure with microtag
and macrotag formation (Figure 14-7, A), one finds an
irregular but smooth hybrid layer, 3 to 4 µm thick and
irregular tag formation with no apparent indentations
of enamel prism or core material. The minimal etch
obtained with the SEPs indicates that the majority of
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the bond may be more of a chemical bond with the
calcium in the enamel than the mechanical bond
achieved with a conventional phosphoric acid etch.215
Clinical procedure: For optimal bonding with the SEP
Transbond Plus (3M/Unitek), the authors recommend
the following sequence (Figure 14-8):
1. Dry the tooth surface.
2. Apply Transbond Plus. The single-use package
consists of three compartments. The first
compartment contains methacrylated phosphoric
acid esters, photosensitizers, and stabilizers. The
second compartment contains water and soluble
fluoride. The third compartment contains an
applicator microbrush (Figure 14-8, A and B).
Squeezing and folding the first compartment over
to the second activates the system. The mixed
component then is ejected to the third to wet the
applicator tip. Stay on the tooth surface to avoid
gingival irritation. Rub thoroughly for at least
3 seconds and always wet the surface with new
solution to ensure the monomer penetration
(Figure 14-8, C and D). The presence of water
in the chemical composition of Transbond
Plus may necessitate air drying, but as the
operator moves from one side to the other, the
solvent evaporates and drying is no longer
necessary.
3. Bond the bracket with Transbond XT (3M/Unitek)
and cure with light.
B
A
Figure 14-7
C
Comparison of scanning electron microscopy views of
adhesive under the bracket base after phosphoric acid
etching and use of self-etching primer (Transbond Plus).
A, Adhesive under the bracket base after removal of
phosphoric acid-etched enamel. Note exact replica of
honeycomb appearance (×1500). B, Cross section showing Transbond Plus–treated enamel and outer surface of
Transbond Plus layer on enamel (×2000). C, Adhesive
under the bracket base after complete removal of the
Transbond Plus–treated enamel (×1500).
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A
B
C
D
Figure 14-8
Application of self-etching primer (Transbond Plus) on enamel surface of maxillary incisor (see text for
explanation).
The use of the new SEPs for orthodontic purposes has
not yet been evaluated fully. Recent laboratory studies35
indicate that the shear bond strength of mix (Transbond
Plus) and no-mix (Ideal 1, GAC International, Bohemia,
New York) SEPs were not significantly different from one
another. In the authors’ in vitro study,48 the shear bond
strengths of the acidic primer Transbond Plus was significantly higher than that obtained with conventional
37% phosphoric acid etching.
Clinical bond strengths using SEPs are not yet reported
in a large sample for a full period of orthodontic treatment. In a 6-month clinical test period, Ireland et al.115
found that bond failures with an SEP were higher than
those with conventional etching and priming. The
author’s experience since June 2001 (Büyükyilmaz,
unpublished findings) with more than 2300 brackets
and tubes on 106 patients indicates a reasonably low
failure rate (4.1%), which still is significantly higher
than the authors’ failure rates for conventional phosphoric acid etching. Debonding brackets after SEP application also is easier and requires shorter time to remove
the adhesive compared with acid etching.
When deciding which etching and priming system to
use, each clinician must weigh bond failure rates against
the time saved in bonding and debonding.
Figure 14-9
Instruments used for bracket bonding with self-etching
primer (Transbond Plus) and light-initiated adhesive
resin (Transbond XT).
Bonding
Immediately after all teeth to be bonded have been
painted with sealant or primer, the operator should
proceed with the actual bonding of the attachments
(Figure 14-9). At present, the majority of clinicians
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Chapter 14 • Bonding in Orthodontics
routinely bond brackets with the direct rather than the
indirect technique.128
In a 2002 survey in the United States, more than 90%
of orthodontists routinely were using direct bonding.
Indirect bonding was used routinely by about 10%.
Remarkably, now about 75% of the U.S. specialists have
replaced the chemically cured one- or two-paste adhesives
and have adopted the light-initiated bonding resins.128
Many different adhesives exist for direct bonding,
and new ones appear continuously. However, the basic
bonding technique is only slightly modified for varying
materials according to each manufacturer’s instructions.
The easiest method of bonding is to have a slight excess of
adhesive to the backing of the attachment (Figure 14-10)
and then place the attachment on the tooth surface in
its correct position.
When bonding attachments one at a time with new
adhesive, the operator can work in a relaxed manner
and obtain optimal bond strength for each bracket.
Hurrying is not necessary because plenty of time is
available for placing the bracket in its correct position,
checking it, and if necessary repositioning it within the
working time of the adhesive or before light curing.
The recommended bracket bonding procedure251,263
(with any adhesive) consists of the following steps:
1. Transfer
2. Positioning
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3. Fitting
4. Removal of excess
Transfer. The clinician grips the bracket with reverse
action tweezers and then applies the mixed adhesive to
the back of the bonding base. The clinician immediately
places the bracket on the tooth close to its correct position (Figure 14-11).
Positioning. The clinician uses a placement scaler
to position the brackets mesiodistally and incisogingivally and to angulate them accurately relative to the
long axis of the teeth (Figure 14-11, A). Proper vertical
positioning may be enhanced by different measuring
devices or height guides. A mouth mirror will aid
in horizontal positioning, particularly on rotated
premolars (Figure 14-12).
Fitting. Next, the clinician turns the scaler and with
one-point contact with the bracket, pushes firmly toward
the tooth surface.121 The tight fit will result in good
bond strength, little material to remove on debonding,
optimal adhesive penetration into bracket backing, and
reduced slide when excess material extrudes peripherally. The clinician should remove the scaler after the
bracket is in the correct position and should make no
attempts to hold the bracket in place with the instrument. Even slight movement may disturb the setting of
the adhesive. Totally undisturbed setting is essential for
achieving adequate bond strength.263
A
B
C
Figure 14-10
Placement of chemically curing (A) and light-curing (B to D) adhesive resin on contact surface of bracket.
D
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B
A
Figure 14-11
Direct bracket bonding with light-cured adhesive resin.
A, After the bracket is transferred to the tooth surface,
orientation (angulation, height, mesiodistal position) is
made with placement scaler. B, Next, the scaler is used
to seat the bracket firmly toward the tooth surface.
Excess adhesive is removed with the scaler along the pad
periphery. C, Light curing.
Figure 14-12
Bracket position on difficult teeth may be checked with
a mouth mirror.
Removal of Excess. A slight bit of excess adhesive is
essential to minimize the possibility of voids and to be
certain that the adhesive will be buttered into the bracket
backing when the bracket is being fitted. The excess is
particularly helpful on teeth with abnormal morphology.
Excess adhesive will not be worn away by toothbrushing
and other mechanical forces (Figure 14-13); it must be
removed (especially along the gingival margin) with the
scaler before the adhesive has set (see Figure 14-11, B)
or with burs after setting (Figure 14-14).
Most important is to remove the excess adhesive
to prevent or minimize gingival irritation and plaque
C
buildup around the periphery of the bonding base
(Figures 14-15 and 14-16). Removal of excess adhesive
reduces periodontal damage and the possibility of decalcification. Clinically significant gingival hyperplasia and
inflammation rapidly occur when excess adhesive comes
close to the gingiva and is not removed properly.251,263 In
addition, removal of excess adhesive can improve esthetics not only by providing a neater and cleaner appearance
but also by eliminating exposed adhesive that might
become discolored in the oral environment.
When the procedure just described has been repeated
for every bracket to be bonded, the clinician carefully
checks the position of each bracket (see Figure 14-12).
Any attachment that is not in good position should be
removed with pliers and rebonded immediately. After
inserting a leveling arch wire, the clinician instructs the
patient how to brush properly around the brackets and
arch wires and gives a program of daily fluoride mouth
rinses (0.05% NaF) to follow.249
Bonding to Premolars. The most difficult technical
problem for bonding to maxillary first and second premolars is to obtain accurate bracket placement. The visibility
for direct bonding is facilitated if these teeth are bonded
without a lip expander, one side at a time. Bracket positions should be controlled using a small mouth mirror.
For newly erupted mandibular premolars, gingivally
offset brackets are recommended. The gingival third of
these teeth may have a high incidence of aprismatic
enamel and an enamel rod direction that is less retentive of resin tags.213
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B
C
D
E
589
A
Figure 14-13
Typical wear pattern of excess adhesive (EA). Scanning electron micrographs of a replica model (A), at the
time of bonding (B and D), and 6 months later (C and E). An example of abrasive wear of adhesive with
large filler particles is shown in B and C and of adhesive with submicrometer-sized fillers in D and E.
Br, Bracket; BP, bracket pad; BS, bracket slot; BW, bracket wing; ES, enamel surface.
A
B
Figure 14-14
C
Bonding to Molars. With the difficulty of banding
in young patients, particularly second molars, bonding
these and other molars is advantageous. With special
technique and care (see Figure 14-3), the routine bonding
of first, second, and third molars can be accomplished
with high success rates.
A and B, Use of a large (#7006) and a small oval tungsten carbide bur for removal of set adhesive around the
bracket base and along the gingival margin, respectively.
C, Small burs are also useful under ceramic bracket
tie-wings.
Recently introduced resin-modified glass ionomer
cements (chemical and light cured) claim to be able to
bond to saliva-contaminated enamel surfaces without
phosphoric acid etching.197 This is an attractive feature,
but these cements have a disadvantage when bonding
molar attachments. The liquid contains polyacrylic and
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Figure 14-16
Irrespective of the bonding technique, poor oral hygiene
invariably results in significant hyperplastic gingival
changes. This has occurred even though excess adhesive
was removed carefully.
Types of Adhesives
Figure 14-15
Relationship between excess adhesive (EA) and gingival
inflammation. Note the hyperplastic gingival changes
on the distal aspect (open arrow), where excess adhesive
is close to the gingival margin. Less reaction occurs on
the mesial aspects, where adhesive is farther from the
gingiva.
maleic acids, which will remove contaminants and change
the enamel surface mechanically but will not create
micromechanical retention as well as 37% phosphoric
acid does. The bond strength with resin-modified glass
ionomer cements is significantly lower than that of
composite resins after phosphoric acid etching.77,133,244
For optimal bond strength, it appears preferable to
establish adequate moisture control and bond molar
attachments with conventional bisphenol A diglycidyl
dimethacrylate (bis-GMA) composite resins. The following procedure is recommended for direct bonding
of molars:
1. The first and second molars (and third, if applicable) are bonded separately from the other teeth to
permit concentration on access, visibility, and moisture control.
2. A dry field is obtained by a Dri-Angle in the
buccal side and a cotton roll. The saliva ejector
is positioned on the side to be bonded, adjacent
to the second molar. The scaler or a cotton roll is
placed over the Dri-Angle for tissue retraction
(see Figure 14-3).
3. The bonding procedures are performed on one side
at a time.
Two basic types of dental resins may be used for
orthodontic bracket bonding. Both are polymers and
are classified as acrylic or diacrylate resins. Both types of
adhesive exist in filled or unfilled forms. The acrylic resins
(e.g., Orthomite [Sun Medical, Tokyo, Japan] and Genie
[Lee Pharmaceuticals, South EI Monte, California]) are
based on self-curing acrylics and consist of methylmethacrylate monomer and ultrafine powder. Most
diacrylate resins are based on the acrylic modified epoxy
resin mentioned in the introduction: bis-GMA or
Bowen’s resin. A fundamental difference is that resins of
the first type form linear polymers only, whereas those
of the second type may be polymerized also by crosslinking into a three-dimensional network. This crosslinking contributes to greater strength, lower water
absorption, and less polymerization shrinkage.182
A number of independent investigations indicate
that the filled diacrylate resins of the bis-GMA type (e.g.,
Concise [3M, St. Paul, Minnesota] and Phase-II [Reliance
Orthodontics]) have the best physical properties and
are the strongest adhesives for metal brackets.51,121,263
Acrylic or combination resins have been most successful
with plastic brackets. Some composite resins contain
large, coarse quartz or silica glass particles of highly variable size averaging 3 to 20 µm41 that impart abrasionresistance properties. Other resins contain minute filler
particles of uniform size (0.2 and 0.30 µm) that consequently yield a smoother surface that retains less plaque263
and is more prone to abrasion.41 Reported failure rates
for steel mesh–backed brackets direct bonded with highly
filled diacrylate resins may be as low as 1% to 4%.263
Buzzitta et al.51 found that a highly filled diacrylate resin
with large filler particles gave the highest values of in
vitro body strength for metal brackets.
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Chapter 14 • Bonding in Orthodontics
Several alternatives exist to chemically autopolymerizing paste-paste systems.
No-mix adhesives
No-mix adhesives (e.g., Rely-a-Bond [Reliance
Orthodontics] and System 1+ [Ormco Corporation,
Glendora, California]) set when one paste under light
pressure is brought together with a primer fluid on the
etched enamel and bracket backing or when another
paste on the tooth is to be bonded. Thus one adhesive
component is applied to the bracket base while another
is applied to the dried etched tooth. As soon as the
bracket is positioned precisely, the orthodontists presses
the bracket firmly into place and curing occurs, usually
within 30 to 60 seconds.
Although the clinical bonding procedure may be simplified with the no-mix adhesives, little long-term information is available on their bond strengths compared
with those of the conventionally mixed paste-paste
systems. Furthermore, little is known about how much
unpolymerized rest monomer remains in the cured
adhesive220 and its eventual toxicity. In vitro tests have
shown that liquid activators of the no-mix systems are
definitely toxic86,220; allergic reactions have been reported
in patients, dental assistants, and doctors when such
adhesives were used (Figure 14-17).
Light-polymerized adhesives
The desire to cure on demand is driving an increasing
number of orthodontic practices to use light-cured adhesives instead of the more traditional paste-paste adhesives
requiring in-office mixing. The light-initiated resins by
now have become the most popular adhesives for a
majority of orthodontists128 (see Figures 14-9 and 14-10).
These resins offer the advantage of extended, though
not indefinite, working time. This in turn provides the
opportunity for assistants to place the brackets, with the
orthodontist following up with any final positioning.
591
Light-cured resins used with metal brackets are usually
dual-cure resins incorporating light initiators and a chemical catalyst. Maximum curing depth of light-activated
resins depends on the composition of the composite, the
light source, and the exposure time.189,224 Bond strength
for light-activated materials is reported to be comparable in vitro to those of chemically cured composites,217
but the material may not be as reliable in vivo.72,90,194,215
Light-cured adhesives are particularly useful in situations in which a quick set is required, such as when
rebonding one loose bracket or when placing an attachment on an impacted canine after surgical uncovering,
with the risk for bleeding. But light-cured adhesives are
also advantageous when extra-long working time is
desirable. This may be the case when difficult premolar
bracket positions need to be checked and rechecked
with a mouth mirror before the bracket placement is
considered optimal.
Fluoride-releasing, visible light–curing adhesives are
also available,163,226 but further long-term clinical testing
of their bond strength, durability, and caries-preventive
effect is necessary.
Metallic and ceramic brackets precoated with lightcured composite and stored in suitable containers
are practical in use and are becoming increasingly
more popular among clinicians.128 Such brackets
have consistent quality of adhesive, reduced flash,
reduced waste, improved cross-infection control, and
adequate bond strength.34 Recently, some precoated
brands (APC Plus, 3M/Unitek) are provided with a
color change adhesive for easier and more thorough
flash cleanup.
Light sources
The orthodontist has the following options for light
sources:
1. Conventional and fast halogen lights: In light-initiated
bonding resins the curing process begins when a
A
B
Figure 14-17
A, Allergic reaction to bonding adhesive. B, Fingertips of a dental assistant.
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Part II • Techniques and Treatment
photoinitiator is activated. Most photoinitiator
systems use camphoroquinone as the absorber,6
with the absorption maximum in the blue region
of the visible light spectrum at a wavelength of
470 nm. Until recently, the most common method
of delivering blue light has been halogen-based
light-curing units (e.g., Ortholux XT, 3M/Unitek).
Halogen bulbs produce light when electric energy
heats a small tungsten filament to high
temperatures. Despite their common use, halogen
bulbs have several disadvantages. The light power
output is less than 1% of the consumed electric
power, and halogen bulbs have a limited lifetime of
about 100 hours because of degradation of the
components of the bulb by the high heat generated.
The halogen lights can cure orthodontic
composite resins in 20 seconds and light-cured
resin-modified glass ionomers in 40 seconds per
bracket.193 This prolonged curing time is
inconvenient for the clinician and the patient.
Various attempts have been made therefore to
enhance the speed of the light-curing process. Fast
halogens (e.g., Optilux 501 or Demetron from
Kerr, Orange, California) have significantly
higher-intensity output than other current
halogen lights, and this is accomplished by using
higher-output lamps or using turbo tips that focus
the light and concentrate it into a smaller area. By
this means, curing times can be reduced to half of
the time needed with conventional halogen lights.
Limitations of filter technique and thermal
problems make further improvements of
conventional curing lights difficult.
2. Argon lasers: In the late 1980s, argon lasers promised
to reduce the curing times dramatically.216,237 Argon
lasers produce a highly concentrated beam of light
centered around the 480-nm wavelength. In
addition, the light is collimated, which results in
more consistent power density over distance. One
interesting potential of the argon laser is its ability
to protect the lased enamel surface against
decalcification. Recent studies have shown that
argon laser irradiation significantly reduces enamel
demineralization around orthodontic brackets.7,156
Although the curing times could be reduced to
5 seconds for unfilled and 10 seconds for filled
resins with argon laser, their use in orthodontics at
present is not extensive,128 probably because of their
high cost and poor portability.
3. Plasma arc lights: In the mid-1990s, the xenon
plasma arc lamp was introduced for high-intensity
curing of composite materials in restorative
dentistry. This lamp has a tungsten anode and a
cathode in a quartz tube filled with xenon gas.
When an electric current is passed through xenon,
the gas becomes ionized and forms a plasma made
up of negatively and positively charged particles
and generates an intense white light. Plasma arc
lights are contained in base units (Figure 14-18, A)
rather than in guns because of the high voltage used
and heat generated. The light guide is stiff because
of the gel inside. The white light is filtered to blue
wavelengths, with a narrow spectrum between
430 and 490 nm. Whereas the conventional
halogen lamps emit light with an energy level of
300 mW, the plasma arc lamp has a much higher
peak energy level of 900 mW. The advantage of the
high-intensity light is that the amount of light
energy needed for polymerization of the composite
resin can be delivered in a much shorter time.
Recent clinical studies194 indicate that exposure
times of 3 to 5 seconds for metal brackets and even
A
B
Figure 14-18
Light-curing times can be reduced greatly with plasma arc and light-emitting diode light curing sources.
A, PowerPac plasma arc unit. B, Ortholux LED.
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Chapter 14 • Bonding in Orthodontics
shorter times for ceramic brackets129 yield similar
bond failure rates as for brackets cured with a
conventional halogen light for 20 seconds.
Therefore plasma arc lights significantly reduce the
curing time of orthodontic brackets without
affecting the bond failure rate.
The heat generated by the high-intensity lights
and the possibility of harming the pulp tissue have
been addressed in several publications.152,172 In
primates, Zach and Cohen247 reported permanent
pulp damage when the pulpal temperature rose
above 42.5° C. The increase in pulpal temperature
in a restorative preparation was only 2.8° C with
conventional halogen and 1.1° C with plasma arc
light, respectively.16 Thus the use of the plama arc
light for curing orthodontic adhesives for 5 to
10 seconds should be safe regarding the pulp
temperature.160
4. Light-emitting diodes (LEDs): The most recent light
source category is the LED sources (Figure 14-18, B).
In 1995 Mills et al.151 proposed solid-state LED
technology for polymerization of light-initiated
resins to overcome the shortcomings of conventional
halogen lights. Light-emitting diodes use junctions
of doped semiconductors to generate the light. They
have a lifetime of more than 10,000 hours and
undergo little degradation of output over this time.
Light-emitting diodes require no filters to produce
blue light, resist shock and vibration, and take little
power to operate. The authors’ in vitro results229
suggest that LED curing of 20 and 40 seconds
yielded statistically similar results to curing of
40 seconds by conventional halogen light sources.
However, 10 seconds of LED curing (Elipar
FreeLight, 3M/ESPE) resulted in significantly
reduced shear bond strength values. The longer life
span and more consistent light output of LEDs
compared with halogen bulb technology show
promise for its use in orthodontics. New-generation
LEDs with higher-intensity diodes may shorten the
curing times further (e.g., the new Ortholux LED by
3M/Unitek [see Figure 14-18, B] has recommended
curing times of 10 seconds for metal and 5 seconds
for ceramic brackets), but further studies and clinical
trials should be performed before validation.
In conclusion regarding the use of different light sources
and light-initiated adhesives, the authors’ laboratory
studies provided the following results:
• The light source and adhesive must be compatible.
• All new light sources cure resins faster than
conventional halogen lights.
• Fast halogen sources are more brand specific but
generate low heat and are less expensive than
plasma lights and LEDs.
• Plasma arc lights offer the shortest curing times but
are expensive and generate heat.
593
• Light-emitting diodes have small size, are cordless,
are quiet, generate minimal heat, and perform
favorably compared with conventional and fast
halogen sources.
Glass ionomer cements
The glass ionomer cements were introduced in 1972, primarily as luting agents and direct restorative material,
with unique properties for bonding chemically to
enamel and dentin and to stainless steel and being able
to release fluoride ions for caries protection. The secondgeneration water-hardening cements contain the same
acids in freeze-dried form or an alternative powdered
copolymer of acrylic and maleic acids. The glass ionomer
cements were modified to produce dual-cure or hybrid
cements (e.g., Fuji Ortho LC, GC America, Alsip, Illinois).
Glass ionomer and light-cured glass ionomer cements
now are used routinely by most orthodontists128 for
cementing bands because they are stronger than zinc
phosphate and polycarboxylate cements, with less
demineralization at the end of treatment87,137,150 and
adhesion to enamel and metal.114 However, glass ionomer
cements are susceptible to moisture contamination during the setting reaction and require up to 24 hours to
reach maximum strength.243 The light-activated resinmodified glass ionomers are faster setting and show
higher initial and sustained shear bond strengths than
the chemically cured ones.
The chemical composition and setting reaction among
resin ionomer hybrids vary widely. Some hybrids are categorized as modified composites (compomers or polyacid
modified composite resins) and others as true resin modified glass ionomer cements. The compomers are essentially resin matrix composites, where the filler is replaced
by ion-leachable aluminosilicate glass. No acid-base reaction occurs during setting, but often a light-activated free
radical polymerization of the methacrylate groups occurs.
In contrast, the resin-modified glass ionomer cements are
hybrids of their two parent groups and incorporate an
acid-base reaction in the setting process.147,155
Few reports are available about the clinical performance over a substantial time for resin-modified glass
ionomer cements for bracket bonding. In 1999 Gaworski
et al.92 published the results comparing a glass ionomer
(Fuji Ortho LC) with a composite resin (Light Bond,
Reliance Orthodontics) for bonding brackets over 12
to 14 months. The failure rates were 24.8% and 7.4%,
respectively, with no statistical difference in incidence of
decalcification between the two adhesives. When polyacrylic acid was used for conditioning and no saliva
contamination occurred, Hitmi et al.108 found a failure
rate of 7% for Fuji Ortho LC. Conditioning with polyacrylic acid removes surface contaminants and alters
the surface energy by diffusion of the acid and exchange
of ions. The pretreatment with polyacrylic acid facilitates a chemical bond between the glass ionomer and
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Part II • Techniques and Treatment
the enamel and thus should be performed before
bracket bonding with glass ionomer. In a double-blind,
randomized, controlled clinical trial by Gorton and
Featherstone,99 the quantitative microhardness tests of
teeth bonded with Fuji Ortho LC showed significantly
less mineral loss compared with teeth bonded with
light-cured composite resin (Transbond XT). When bond
strength is the main criterion for selecting an adhesive,
composite resins are recommended. However, the decalcification risk with fixed orthodontic appliances in some
patients should not be ignored, and the use of fluoridereleasing cements may have an impact in preventing
this phenomenon.
Selection of adhesives for direct bonding among the
myriad alternatives available depends largely on what
handling characteristics are preferred and on the individual office philosophy regarding delegation (Figure 14-19).
Bond failures, which are failures at the enamel-adhesive
interface (adhesive failures), are likely to result from inadequate technique (e.g., inadequate etch or moisture or
saliva contamination with the pellicle). Failures in the
adhesive-bracket interface (cohesive failures) more likely
are caused by moving the bracket during the initial polymerization, applying an excessive load to the bracket
while the resin is still polymerizing, or simply that too
little pressure was used when the adhesive resin was
pushed into the mesh base of the bracket.
The incidence of cohesive-type bond failures may
increase with the adoption of light-initiated bonding
adhesives. The polymerization of bonding materials is a
chain reaction. The light cannot penetrate entirely under
metal brackets. The polymerization only begins at the
edges of the bracket base and then continues as a chain
reaction. The light-initiated bonding resins under metal
brackets may take as long as 3 days to reach maximum
polymerization or strength.215 The set under clear brackets, however, is almost instantaneous.
An important factor related to cohesive-type bond
failures with light-initiated resins is moving the bracket
after the resin has begun to set. The operatory light in the
B
A
C
Figure 14-19
The bond strength of adhesives is satisfactory for bonding lower second molars routinely. A problem may be
encountered, however, in arch wire removal. The problem is solved with the following technique: A, A distally
bent-over arch wire from a bonded second molar is loosened by a Coon or Steiner tying pliers and a Mathieu
needle holder. The needle holder acts as a stop on the arch wire a few millimeters from the mesial end of the
buccal tube. B, The Coon pliers rest at the mesial part of the tube and at the stop. By closing the tying pliers,
the operator gently releases the arch wire, often without even needing to straighten the arch wire at the distal
end of the tube. C, Because the pressure is equal on both ends of the buccal tube, the bond is not stressed unduly.
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Chapter 14 • Bonding in Orthodontics
office may be starting the polymerization. For success in
bonding with light-activated resins, a recommendation
is that the clinician expose the bracket to the curing light
immediately after placement or keep the time interval
between placement and curing to a minimum.216
Brackets
Three types of attachments are presently available for
orthodontic bracket bonding: plastic based, ceramic
based, and metal (stainless steel, gold-coated, titanium)
based. Of these, most clinicians prefer the metal attachments for routine applications, at least in children.128
Plastic brackets
Plastic attachments are made of polycarbonate and are
used mainly for esthetic reasons. Pure plastic brackets
lack strength to resist distortion and breakage, wire slot
wear (which leads to loss of tooth control), uptake of
water, discoloration, and the need for compatible bonding resins.182 Such plastic brackets may be useful in
minimal-force situations and for treatments of short
duration, particularly in adults. New types of reinforced
plastic brackets with and without steel slots inserts have
been introduced. Steel-slotted plastic brackets are useful
as an esthetic alternative, but added bulk is required to
provide adequate strength of the tie-wings.
Ceramic brackets
Ceramic brackets have become an important though
sometimes troublesome part of today’s orthodontic practice. Ceramic orthodontic brackets are machined from
monocrystalline or polycrystalline aluminum oxide.32,212
Theoretically, such brackets should combine the
esthetics of plastic and the reliability of metal brackets.
595
In contrast to current elastic ligatures, polycrystalline
and single-crystal brackets resist staining and discoloration. Steel ligatures can be used with caution.83,84,212
Ceramic brackets bond to enamel by two different
mechanisms: (1) mechanical retention via indentations
and undercuts in the base and (2) chemical bonding by
means of a silane coupling agent. With mechanical retention the stress of debonding is generally at the adhesivebracket interface, whereas the chemical bonding may
produce excessive bond strengths, with the stress at
debonding shifted toward the enamel-adhesive interface
(see Debonding). Chemically cured and light-cured adhesives are useful for ceramic brackets.53,159,212 Brackets preloaded with light-cured paste can be applied to the teeth
and pressed firmly in place in their approximate location. After adjusting the brackets and removing excess
adhesive, the operator bonds the brackets in place with
the curing light.161
However, the pure ceramic brackets that are available
show some significant drawbacks:
1. The frictional resistance between orthodontic
wire and ceramic brackets is greater and less
predictable than it is with steel brackets.29,95,116,136
This unpredictability makes determining
optimal force levels and anchorage control
difficult. Ceramic brackets with a steel slot insert
(Figure 14-20; see Figure 14-22) to reduce
friction32,52,53 are therefore more reliable for
clinical purposes.
2. Ceramic brackets are not as durable as steel
brackets and are brittle by nature. These brackets
may break during orthodontic treatment,
particularly when full-size (or close to full-size)
stainless steel arch wires are used for torquing
purposes.84,112
B
A
Figure 14-20
A, Steel-slotted ceramic brackets (Clarity) just bonded in adult patient. Note that canine and right central
incisor brackets in this case are angulated to move the root apices of these teeth apart with the purpose of
providing adequate space for later single-implant insertion. B, Right lateral incisor is acrylic pontic bonded
to central incisor. Color dots for bracket orientation will soon disappear.
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Part II • Techniques and Treatment
3. Ceramic brackets are harder than steel and rapidly
induce enamel wear of any opposing teeth.
4. Ceramic brackets are more difficult to debond
than steel brackets, and wing fractures may occur
easily during debracketing.33,203,218
5. The surface is rougher and more porous than
that of steel brackets and hence more easily
attracts plaque and stain to the surrounding
enamel.
6. The added bulk required to provide adequate
strength makes oral hygiene more difficult.126
Metal brackets
Metal brackets rely on mechanical retention for bonding,
and mesh gauze is the conventional method of providing
this retention.128 Photoetched recessions or machined
undercuts are also available.
The area of the base itself is probably not a crucial
factor regarding bond strength with mesh-backed brackets. The use of small, less noticeable metal bases helps
avoid gingival irritation. For the same reason, the base
should be designed to follow the tissue contour along
the gingival margin. The base must not be smaller than
the bracket wings, however, because of strength reasons141
and the danger of demineralization around the periphery. The mandibular molar and premolar bracket wings
must be kept out of occlusion, or the brackets may come
loose easily. Therefore before bonding, the operator
should do the following:
1. Ask the patient to bite with teeth together; the
operator then should evaluate the tooth area
available for bonding.
2. Bond mandibular posterior brackets out-ofocclusion, which may necessitate adjustment
bends in the arch wires.
3. Evaluate any occlusal interference on mandibular
posterior attachments immediately after bonding.
Occlusal tie-wings in contact with maxillary
molar/premolar cusps should be spot ground
(with green stone or similar). Using these
procedures, the authors have been successful
in routinely bonding mandibular molar and
premolar attachments in children and adults.
Corrosion of metal brackets may be a problem,145
and black and green stains have appeared with bonded
stainless steel attachments.58,142 Crevice corrosion of
the metal arising in areas of poor bonding may result
from the type of stainless steel alloy used.142 However,
other factors such as galvanic action, bracket base
design and construction, particular oral environment,
and thermal recycling of brackets109,145 may be contributing factors (for review, see von Fraunhofer233).
Because of the corrosion susceptibility of stainless steel,
interest is growing in the use of more corrosion-resistant and biocompatible bracket metals such as titanium
(see Chapter 9).71,128,233
Gold-coated brackets
Gold-coated steel brackets (see Figures 14-1, C, and
14-23) have been introduced and have gained considerable popularity, particularly for maxillary premolars
and for mandibular anterior and posterior teeth. In lack
of entirely satisfactory tooth-colored or clear brackets,
the gold-coated brackets may be regarded as an esthetic
improvement over stainless steel attachments, and they
are neater and thus more hygienic than ceramic alternatives. Patient acceptance of gold-coated attachments
is generally positive. In the authors’ own practices,
gold-coated brackets are being used increasingly, particularly for adults (see Figures 14-23 and 14-59). Side
effects in the form of corrosion or other adverse effects
have not been observed clinically, at least not with the
pioneer brand of gold-coated brackets (Gold’n Braces
Inc., Palm Harbor, Florida).
Bonding to crowns and restorations
Many adult patients have crown and bridge restorations fabricated from porcelain and precious metals in
addition to amalgam restorations of molars. Banding
becomes difficult, if not impossible, on the abutment
teeth of fixed bridges. Recent advances in materials
and techniques indicate, however, that effective bonding of orthodontic attachments to nonenamel surfaces
now may be possible (for review, see Zachrisson260 and
Zachrisson and Büyükyilmaz264). Particularly, the
Microetcher (Danville Engineering, San Ramon,
California) (Figure 14-21), which uses 50 µm white or
90 µm tan aluminum oxide particles at about 7 kg/cm2
pressure, has been advantageous for bonding to different artificial tooth surfaces. This tool is also useful for
tasks such as rebonding loose brackets, increasing the
retentive area inside molar bands,150 creating micromechanical retention for bonded retainers, and bonding to
deciduous teeth.
Bonding to porcelain
Orthodontic brackets and retainer wires may have to
be fitted to adult patients who have porcelain surfaces
on some teeth. Most dental ceramic and metal ceramic
crowns, bridges, and veneers presently are made from
different feldspathic porcelains containing from 10% to
20% aluminum oxide. However, such restorations also
can be made from high-aluminous porcelains and glass
ceramics.271
Conventional acid etching is ineffective in the preparation of porcelain surfaces for mechanical retention of
brackets. In 1986 Wood et al.246 showed that roughening
the porcelain surface, adding a porcelain primer, and
using a highly filled adhesive resin when bonding to
glazed porcelain added progressively to bond strength.
Their in vitro findings indicated that the bond strength
to porcelain equaled or surpassed that obtained after
bonding to acid-etched enamel of natural teeth.
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Chapter 14 • Bonding in Orthodontics
A
597
B
Figure 14-21
C
Therefore they warned that the bond strength was high
enough to damage the porcelain tooth surface during
debondings. Similar concerns have been expressed by
others.64,75,119-124,204
However, cracks or fractures occurring in porcelain
crowns or laminate veneers during debonding by
machines in laboratory studies may not reflect the clinical situation adequately. In vitro and in vivo bond
strengths may differ significantly, and it is possible to
debond metal and ceramic brackets clinically much
more gently than is done with laboratory machines and
to secure an adhesive-bracket separation with all adhesive remaining on the tooth surface. Several studies have
reported that roughening of porcelain and silane treatment may produce in vitro bond strengths that also
should be clinically successful64,75,84,204; however, these
claims have not been verified by clinical investigations8
or by the authors’ own experiences. Furthermore, other
authors have claimed that the composite-porcelain
bond is mostly micromechanical and that the contribution of the silane application for a chemical bond
to most feldspathic porcelains is negligible.207,208 The
clinical effectiveness of single-component liquid silanes,
unhydrolyzed (Porcelain Primer, Ormco, Orange,
California) and prehydrolyzed (Scotchprime, 3M), have
been questioned compared with a new generation of
two- and three-liquid primers with separate silane coupler and acid activator.3,146
Therefore the concept of etching porcelain with
hydrofluoric acid4,105,202 to provide an even more retentive
The Microetcher II is an intraoral sandblaster approved
by the Food and Drug Administration that is most useful
for preparing microretentive surfaces in metals and other
dental materials, whenever needed. A, 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. The
Microetcher is also useful for removing old composite
resin and improving the retentive surface of loose
brackets before rebonding (B) and the inside of the
stainless steel molar bands (C).
surface is interesting to orthodontists. The most commonly used porcelain etchant is 9.6% hydrofluoric
acid in gel form applied for 2 minutes. Hydrofluoric
acid is strong and requires bonding separately to other
teeth, careful isolation of the working area, cautious
removal of gel with cotton roll, rinsing with highvolume suction, and immediate drying and bonding
(Figure 14-22). The etchant creates microporosities on
the porcelain surface that achieve a mechanical interlock with the composite resin.4,202 The etched porcelain
will have a frosted appearance similar to that of etched
enamel.
As mentioned, interpretation of the results obtained
in laboratory studies on bonding to porcelain is difficult. One of the reasons is that rigorous thermocycling
of the bonds appears necessary to approximate the
clinical reality.271 Furthermore, to be representative, the
bond failures must occur in the adhesive interface and
not cohesively in one of the materials to the side of the
interface.
Even when these requirements are met, the chairside
experiences may differ significantly from the laboratory
observations. Thus the authors271 recently found in vitro
that two different techniques—namely, (1) hydrofluoric
acid gel treatment and (2) sandblasting and silane
(Scotchprime)—produced equally strong bonds to a
feldspathic porcelain. The authors’ clinical experience
is considerably different. Sandblasting and silane
bonds have been found to be unreliable, with unacceptably high failure rates, whereas the hydrofluoric acid
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Part II • Techniques and Treatment
A
B
C
D
E
F
Figure 14-22
Technique for bracket bonding to porcelain surfaces includes reliable soft tissue retraction and bonding of
the crown separately from other teeth. An area slightly larger than the bracket base is deglazed (A and B)
before the hydrofluoric acid etching gel is applied for 2 minutes (C). The gel is removed with cotton roll (D),
and the teeth are rinsed with water and air spray under high-volume suction (E). F shows final result.
gel–conditioned bonds to porcelain have proved to be
excellent throughout full routine orthodontic treatment
periods (Figures 14-23 and 14-24). In the authors’
hands, the addition of silane (Scotchprime) after
sandblasting and hydrofluoric acid treatment did not
influence the bond strengths significantly (failure rates
of 8.2% versus 8.6%).
For optimal bonding of orthodontic brackets and
retainer wires to porcelain surfaces, the following technique is recommended (see Figure 14-22):
1. Isolate the working field adequately; bond the
actual crown separately from the other teeth.
2. Use a barrier gel such as Kool-Dam (Pulpdent,
Watertown, Massachusetts) (Figure 14-25) on
mandibular teeth and whenever a risk exists that the
hydrofluoric acid etching gel may flow into contact
with the gingiva or soft tissues.
3. Deglaze an area slightly larger than the bracket base
by sandblasting with 50-µm aluminum oxide for
3 seconds.
4. Etch the porcelain with 9.6% hydrofluoric acid gel
for 2 minutes.
5. Carefully remove the gel with cotton roll and then
rinse using high-volume suction.
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A
B
C
D
Figure 14-23
Orthodontic attachment bonded to porcelain-fused-to-metal crown on the left first mandibular molar in an
adult female patient after hydrofluoric acid gel conditioning. Clinical appearance at start (A), during (B and
C), and after treatment (D). Note that the molar bracket tolerated a solid rectangular stainless steel arch wire
and heavy Class II elastic force (C) without coming loose.
A
B
Figure 14-24
Five-unit maxillary lingual retainer bonded to porcelain and amalgam restorations. A, Occlusal view before
treatment. B, The left lateral incisor is the abutment of a three-unit metal-ceramic bridge, and the right canine
has a large amalgam restoration.
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A
B
Figure 14-25
A and B, When hydrofluoric acid gel is used close to the
gingival margin, particularly in the mandible, one must
use a light-cured blockout resin such as Kool-Dam to
protect the soft tissues from the acid. C, A lower molar
bracket must be positioned out of occlusion with the
opposing teeth to avoid bracket loosening. If this is not
possible, the tie-wing in contact with the upper molar
(usually the distal wing) should be ground with green
stone.
6. Immediately dry with air, and bond bracket.
The use of a silane is optional.
Hydrofluoric acid will not be effective for bonding
to high-alumina porcelains and glass ceramics,22 and
new technique improvements are needed for successful orthodontic bonding to such teeth. A newly introduced alternative technique to the use of hydrofluoric
acid gel may be silica coating,192 but further clinical
trials are needed to obtain experience with the silica
coating technique.
At debonding a gentle technique is necessary to achieve
failure at the bracket-adhesive interface and avoid porcelain fracture. A 45-degree outward peripheral force should
be applied to the gingival tie-wings of twin metal brackets
with an anterior bond-removing plier (see Figure 14-39)
or the wings should be squeezed. The residual adhesive
can be removed with a tungsten carbide bur. Ceramic
brackets that do not come off easily can be ground away
with diamond instruments and adequate cooling.234 The
porcelain surface is restored in a two-step procedure.
Smoothing 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 specially designed points incorporating such
paste271 (see Figure 14-23, D).
Bonding to amalgam
Improved techniques for bonding to amalgam restorations may involve (1) modification of the metal
C
surface (sandblasting, diamond bur roughening;
Figures 14-26 and 14-27), (2) the use of intermediate
resins that improve bond strengths (e.g., All-Bond 2
[Bisco, Schaumburg, Illinois], Enhance, and Metal
Primer [Reliance Orthodontics]), and (3) new adhesive
resins that bond chemically to nonprecious and precious metals (e.g., 4-methacryloxyethyl trimellitate
anhydrid [4-META] resins and 10-MDP bis-GMA
resins).101,265
Similar to the bonding to porcelain, apparently a
positive correlation does not exist between laboratory
and clinical findings when it comes to orthodontic
bonding to amalgam fillings. In vitro bonds to amalgam are significantly weaker than for similar brackets
bonded to enamel of extracted human teeth.49,265
However, the clinical performance with different techniques is satisfactory. In the first amalgam study in the
authors’ laboratory,265 mean tensile bond strength to
sandblasted amalgam tabs ranged from 3.4 to 6.4 MPa,
in contrast to control bonds to human enamel of 13.2
MPa. The strongest bonds to amalgam were obtained
with a 4-META adhesive (Superbond C&B, Sun Medical,
Kyoto, Japan), but an intermediate resin (All-Bond 2)
and Concise produced bonds that were comparable to
those of Superbond C&B.
A follow-up in vitro study with different intermediate primers on the three main types of dental amalgams (spherical, lathe cut, admixed) showed better
results for two 4-META primers (Metal Primer [Reliance
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DB
SB
A
B
0.1 mm
0.1 mm
Figure 14-26
Scanning electron photomicrographs of a sandblasted (A) and diamond bur–roughened (B) metal surface.
The use of the Microetcher for about 3 seconds (SB) provided excellent micromechanical retention, whereas
periodic ridges and grooves produced by medium-grit diamond bur (DB) have few undercuts for mechanical
retention. Bar is 0.1 mm.
A
B
C
D
Figure 14-27
E
A, During air abrasion, high-velocity evacuation is necessary. B and C, Intraoral sandblasting of amalgam
restorations produces frosted appearance, indicating
increased micromechanical retention (see Figure 14-26,
A). D and E show convertible cap removal on attachment bonded to amalgam only on mandibular first
molar and indicate strength of bond.
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AB2
Probability of failure (%)
AP
RMP
MPa
100
90
18
80
16
70
14
60
12
A
a Disperalloy (admixed)
50
10
8
40
6
30
4
20
2
10
0
0
Spherical
Lathe-cut
Admixed
Enamel
(control)
b
a
c
b ANA 2000 (lathe-cut)
B
c Tytin (spherical)
0
5
10
15
Stress (MPa)
Figure 14-28
Tensile bonded strengths of three types of amalgam tested with different intermediate resins (A) and Weibull
curves demonstrating the bond failure at any chosen level of stress (B). Note the difference in reliability
(steeper slope of curve) between the spherical (c) and lathe-cut (b) amalgams. AB2, All-Bond 2; AP,
Amalgambond-Plus; RMP, Reliance Metal Primer. (From Büyükyilmaz T, Zachrisson BU: Improving orthodontic
bonding to silver amalgam. II. Lathe-cut, admixed and spherical amalgams with different intermediate resins, Angle
Orthod 68(4):337, 1998.)
Orthodontics], Amalgambond-Plus [Parkell, Farmingdale,
New York) than for All-Bond 2 (Figure 14-28).49 Clinical
observations since February 1996 have confirmed these
results. One must emphasize that all bracket tie-wings
were kept out of occlusion by placement or grinding off
tie-wings in occlusion.
The following procedure is recommended for bonding to amalgam:
Small amalgam filling with surrounding
sound enamel
1. Sandblast the amalgam alloy with 50-µm aluminum
oxide for 3 seconds (see Figure 14-27, A to C).
2. Condition surrounding enamel with 37%
phosphoric acid for 15 seconds.
3. Apply sealant and bond with composite resin.
Make sure bonded attachment is not in occlusion
with antagonists.
Large amalgam restoration or amalgam only
(Figure 14-27; see also Figure 14-27)
1. Sandblast the amalgam filling with 50-µm
aluminum oxide 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 composite resin. Make
sure the bonded attachment is not in occlusion
with antagonists.
Of course, amalgam surfaces can be repolished easily
with rubber cups and points after debonding.
Bonding to gold
In contrast to bonding to porcelain and amalgam, excellent bonding to gold crowns does not yet seem to be
available to orthodontic clinicians. This is surprising in
light of the high bond strengths, which generally have
been reported in different laboratory studies to gold
alloys.50,61,120,157,246 Different new technologies—including
sandblasting, electrolytic tin-plating or plating with
gallium-tin solution (Adlloy),61,157 the use of several
different types of intermediate primer, and new adhesives that bond chemically to precious metals (Superbond
C&B, Panavia Ex and Panavia 21 [Kuraray America, New
York, New York])264—have been reported to improve
bonding to gold in laboratory settings. However, the
high in vitro bond strengths to gold alloys have not been
confirmed by satisfactory clinical results when bonding
to gold crowns.
In the authors’ experience, even a combination of intraoral sandblasting coupled with the use of All-Bond 2 or 4META primers and followed by bracket bonding with
composite resin or special metal-bonding adhesives may
not withstand optimally the occlusal forces in clinical
practice. Tin plating is not approved by the Food and Drug
Administration for intraoral use.157 Clinical studies are
hampered by the fact that bracket bonding to gold restorations or retainer bonding to lingual metal-ceramic crowns
(Figure 14-30) is not occurring frequently in daily practice.
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A
B
C
D
Figure 14-29
Orthodontic attachments bonded to large amalgam restorations on maxillary first and mandibular first and
second molars in an adult Class III patient before (A), during (B and C), and after treatment (D). Note that
super-elastic (B) and rectangular stainless steel arch wires (C) were bent over at the distal of the second molar
during treatment without coming loose.
A
B
Figure 14-30
Bonding to tooth surfaces of gold alloy include bracket bonding to molar crowns (A) and retainer wire
bonding to the lingual of metal-ceramic crowns (right and left lateral incisors and right central incisor in B.
If unfilled 4-methacryloxyethyl trimellitate anhydrid resin is used for retainer bonding, it may be covered
with more abrasion-resistant composite resin. (From Büyükyilmaz T, Zachrisson YØ, Zachrisson BU: Improving
orthodontic bonding to gold alloy, Am J Orthod 108:510, 1995.)
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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.119 However, brackets
bonded to a fresh, roughened surface of old composite
restorations appear to be clinically successful in most
instances.130 Use of an intermediate primer is probably
advantageous as well.119
Lack of clinical relevance in laboratory
studies on bonding
It follows from the previous statements about bonding
to nonenamel tooth surfaces that clinical observations
rarely corroborate laboratory findings. Several reasons
explain this controversy:
1. Different type of load: The debonding force used in
most in vitro studies is a continuously increasing
load applied to the brackets until they come loose.
This load may not be representative for the force
applications that occur in the oral cavity.
2. Different debonding technique: The easiest and
safest method to remove metal bonded brackets
clinically is to rely on the low resistance to peel
force.165 By peripheral concentration of the force,
the brackets come off at low load levels, with little
or no force applied to the tooth. The bonding base
will peel from the adhesive, creating a cohesive
failure and leaving adhesive on the tooth.
Debonding in machines generally is done with
pure shear or tensile force applications at
much higher loads, and the average stress
does not characterize bond strength
adequately.127
3. Different environment: The complex oral
environment, with continually changing
temperature, stresses, humidity, acidity, and
variations in amount and composition of plaque, is
not reproducible in the laboratory.165
Therefore extrapolations from laboratory to clinical
settings on bonding to enamel and nonenamel surfaces
should not be made. Laboratory testing is needed primarily to find out which new products are worth testing
on patients, but only successful clinical performance of
such products over an adequate period of time can provide final proof of efficiency.
Lingual Attachments
A drawback when bonding brackets on the labial surface,
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 (Figures 14-31 and 14-32).
Particularly the palatal intrusion technique is an efficient and simple way to correct excessive distal inclination of maxillary second molars sometimes occurring
after distalization of first molars. When the second molar
palatal cusp is too prominent or, in more extreme cases,
in buccal crossbite, correction with a buccal appliance
alone is difficult or almost impossible because a combination of intrusion, buccal root torque, and palatal
crown movement is needed to avoid balancing aside
interferences.135
Because bonded lingual attachments may be swallowed or aspirated if they come loose, cleats are preferred
to buttons. Cleats may be closed with an instrument
over the elastic module or steel ligature. The bonding
of brackets to the lingual surfaces of teeth is discussed
separately.
A
B
Figure 14-31
Bonding lingual cleats. A, Cleats may be needed in addition to brackets when the maxillary first molars have
been distalized with headgear and the premolars follow the molar. B, Another clinical situation in which
bonding cleats are useful.
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Chapter 14 • Bonding in Orthodontics
A
B
C
D
605
Figure 14-32
The palatal intrusion technique for simultaneous intrusion, buccal root torque, and palatal crown movement
of tipped maxillary second molars uses a cleat bonded
to the lingual surface of the maxillary second molar,
pulling it to a soldered spur on a modified transpalatal
arch (A and B). In extreme cases (D), the second molar
may be in buccal crossbite. B diagrams the resulting
force system. (From Kucher G, Weiland FJ: Goal-oriented
positioning of upper second molars using the palatal intrusion
technique, Am J Orthod 110:466, 1996.)
Ligation of Bonded Brackets
In contrast to brackets on bands, bonded brackets will
not withstand heavy pull into arch wires. Therefore
to learn a few clinical tips on correct ligation is important. Although elastic rings are time saving, they are
plaque-attractive to the extent that their use is contraindicated if one aims at excellent oral hygiene and
healthy gingival conditions in the patients. Steel ties are
safer than elastomers and definitely are more
hygienic.85,263 The rule of thumb in ligation is that the
ligature wire should be twisted with the strand that crosses
the arch wire closest to the bracket wing (Figure 14-33).
This tightens the ligature when the end is tucked under
the arch wire.
To perform active ligations without pulling off any
brackets, the operator should push the arch wire into
the bottom of the bracket slot using the fingers (for flexible wires) and pliers or ligature director for stiffer wires,
and then make a passive ligation. If full engagement is
not possible, the ligature can be retied at the next visit
or elastomers can be added.
Several type of Ligature-less, self-ligating, low-friction
brackets have become available in recent years (e.g.,
SPEED System [Strite Industries, Cambridge, Ontario]
and Damon SL [Ormco]). The popularity of these
brackets seems to be increasing.128 Such brackets may
offer the advantages of saving time, reducing friction,
and probably increasing patient comfort.
Indirect Bonding
Several techniques for indirect bonding are available.
Most are based on the procedures introduced by
Silverman and Cohen.196,198 In these techniques, the
brackets are glued with a temporary material to the
teeth on the patient’s models, transferred to the mouth
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A
B
C
D
Figure 14-33
Technique for active ligation to bonded brackets. A and B, A bend in the rectangular arch wire is made to
correct a contact point in the maxillary incisor region. The arch wire is pushed with pliers or finger toward
the base of the bracket slot before a passive ligation is made. The ligature wire should be twisted so that the
strand that goes over the arch wire closest to the bracket wing (C and D). When not complete, the ligature is
tightened at the next appointment.
with some sort of tray into which the brackets become
incorporated, and then bonded simultaneously with a
bis-GMA resin (Figure 14-34). However, most current
indirect bonding techniques are based on a modification introduced by Thomas.219 In this technique, the
brackets are attached to the model teeth with composite resin to form a custom base (Figure 14-35). A transfer tray of silicone putty or thermoplastic material is
used, and the custom bracket bases then are bonded to
the teeth with chemically cured sealant.
The main advantage of indirect compared with direct
bonding is that the brackets can be positioned more
accurately in the laboratory and the clinical chair time is
decreased. However, the method is technique-sensitive,
and the chairside procedure is more crucial, at least for
inexperienced clinicians; removal of excess adhesive can
be more difficult and more time consuming with some
techniques; the risk for adhesive deficiencies under
the brackets is greater; the risk for adhesive leakage to
interproximal gingival areas can disturb oral hygiene
procedures; and the failure rates with some methods
seem to be slightly higher.131,173,263 Only about 10% of
orthodontists in the United States use indirect bonding
techniques at present.128
Reasons for differences in bond strength between direct
and indirect bonding techniques,263 if any,2 may be as
follows: (1) the bracket bases may be fitted closer to the
tooth surfaces with one-point fitting by a placement
scaler (Figure 14-11) than when a transfer tray is placed
over the teeth, and (2) a totally undisturbed setting is
obtained more easily with direct bonding. However,
when correct technique is used, failure rates with direct and
indirect bonding fall within a clinically acceptable range.
At present, the individual practitioner may use either
method based on practice routine, auxiliary personnel,
and clinical ability and experience. For instance, indirect
bonding is more likely to be used when all brackets are
placed at one time at the start of treatment than with a
progressive strap-up. In lingual orthodontics the indirect technique also is a prerequisite for good bracket
alignment5 because direct visualization has evident
difficulties.
Although bracket placement in the laboratory may
suggest more accurate positioning, this has not been
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Chapter 14 • Bonding in Orthodontics
607
A
B
C
D
Figure 14-34
E
confirmed in studies comparing direct and indirect
bonding. Koo et al.134 found no difference regarding
angulation or mesiodistal bracket position between
direct bonding with light-cured composite resin and an
indirect technique, although bracket height placement
for indirect bonding was better. The differences were
small, and it is questionable whether they are clinically
significant. Aguirre et al.2 showed that neither direct nor
indirect techniques resulted in 100% accuracy of bracket
positioning. More recent computer-assisted measuring
devices for indirect bonding (see Lingual Bracket Bonding:
Invisible Braces) may improve the accuracy of bracket
placement and take into account anatomic variations,
overcorrections, and mechanical deficiencies of preadjusted appliances.148,240,241
Indirect bonding with a silicone transfer tray. A, Brackets
attached to plaster model. B and C, Tray (hard Optosil,
DynaFlex, St. Louis, Missouri). Note the brackets and the
orientation mark in the midline. D, Etching of the right
and left sides simultaneously. Note the difference in
appearance between the central and cervical portions of
the enamel. E, Final appearance following careful
cleanup with instruments and a tungsten carbide bur.
The first premolars were referred for extraction at this
stage. (Courtesy BO Brobakken, Oslo, Norway).
Several products have been introduced recently that
are specifically designed for indirect bonding procedures.
Different types of custom base composites may be light
cured, chemically cured, or thermally cured.130,173 One
system (from Reliance Orthodontics) recommends the
use of thermally cured base composite (Therma-Cure),
Enhance adhesion booster, and a chemically cured sealant
(Custom I.Q.). Another system (from 3M/Unitek) recommends the use of light-cured base composite (Transbond
XT) and chemically cured sealant (Sondhi Rapid Set) in
the clinic (Figure 14-36). Studies comparing the in vitro
bond strengths obtained with these two indirect systems
compared with direct bonding with light-cured composite
resin (Transbond XT) indicate that the differences
between the indirect and direct methods are small and
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A
B
C
D
E
F
Figure 14-35
Indirect bonding using a clear tray (Memosil, Heraeus Kulzer, Armonk, New York) and a light cure adhesive.
probably of little clinical significance. Using single bracket
trays for transfer, Klocke et al.130 found that indirect
bonding with Sondhi Rapid Set showed bond strength
similar to direct bonding with Transbond XT, whereas
indirect bonding with Custom I.Q. showed lower bond
strengths. However, Polat et al.,173 using full-arch transfer trays of putty silicone material, found higher bond
strength when they used thermally cured bracket bases
indirectly bonded with Custom I.Q. than with lightcured bases (Transbond XT) bonded with Sondhi Rapid
Set. In a clinical test for 9 months in 15 patients whose
teeth were indirectly bonded with either of the two
techniques (thermally cured bases bonded with Custom
I.Q. or light-cured bases bonded with Sondhi Rapid Set)
using a split-mouth design, no significant differences in
bond failure rates were found.
Clinical procedure
As mentioned, several indirect bonding techniques
have proved reliable in clinical practice (see Figures 14-34
to 14-36). The techniques differ in the way the brackets
are attached temporarily to the model, the type of transfer tray used (e.g., full-arch, sectioned full-arch, single
tooth, and double-tray system74), the sealant or resin
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A
B
C
D
E
F
Figure 14-36
Indirect bonding using light-cured base composite (Transbond XT) and chemically cured sealant (Sondhi
Rapid Set). See text for details.
used, whether segmented or full bonding is used, and
the way the transfer tray is removed so as not to exert
excessive force on a still-maturing bond.
Indirect bonding with composite custom
bracket base
Most current techniques are modifications of the
Thomas219 technique, which means using composite
resin custom bracket bases (light cured, thermally
cured, or chemically cured), and a chemically cured
sealant as the clinical bonding resin. The following
procedure may be useful (see Figure 14-36):
1. Take an impression and pour up a stone (not
plaster) model.
2. Select brackets for each tooth.
3. Isolate the stone model with a separating
medium.
4. Attach the brackets to the teeth on the model with
light-cured or thermally cured composite resin, or
use adhesive precoated brackets.
5. Check all measurements and alignments.
Reposition if needed.
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6. Make a transfer tray for the brackets. Material can
be putty silicone, thermoplastics, or similar.
7. After removing the transfer trays, gently sandblast
the adhesive bases with a microetching unit,
taking care not to abrade the resin base.205
8. Apply acetone to the bases to dissolve the
remaining separating medium.
9. Prepare the patient’s teeth as for a direct application.
10. Apply Sondhi Rapid Set resin A to the tooth
surfaces and resin B to the bracket bases. (If
Custom I.Q. is used, apply resin B to the teeth and
resin A to the bases).
11. Seat the tray on the prepared arch and with the
fingers apply equal pressure to the occlusal, labial,
and buccal surfaces. Hold for a minimum of
30 seconds, and allow for 2 minutes or more of
curing time before removing the tray.
12. Remove excess flash of resin from the gingival
and contact areas of the teeth with a scaler or
contraangle handpiece and tungsten carbide bur.
Lingual Bracket Bonding:
Invisible Braces
When it became apparent into late 1970s that bonding
of brackets was a viable procedure and that esthetic plastic and ceramic brackets were a compromise, placing the
brackets on the lingual surfaces of the teeth appeared to be
the ultimate esthetic approach (Figures 14-1 and 14-37).
The technique rapidly gained popularity in the early
1980s, but most clinicians experienced considerable difficulties, particularly in the finishing stages,12 and abandoned the technique for routine use.128
The development was pioneered in Japan by Fujita,88
who worked on the mushroom arch, and some American
orthodontists: Kurz (cited in Alexander et al.5), Gorman
and Smith,98 and Creekmore.67 Although treating
malocclusions successfully from the lingual side is
possible,12,88,98,241,242 a combined lingual and buccal segmental approach may offer a number of options with
no great esthetic compromises in most patients.
Surprisingly, the problem with lingual orthodontics
is not that brackets become loose but rather that some
pronunciation difficulties111 occur immediately after
insertion (although the difficulties vary individually
and may disappear within a few weeks88). Furthermore,
the technique is difficult and time consuming, and
the working position is awkward.12,88 More precision is
necessary for the adjustment of lingual arch wires, with
reduced interbracket distance.
If the lingual treatment is to become more important
in the future than at present,128 additional improvements in bracket design and technical aids are needed.
Such changes are under way. Progress in practicability for lingual orthodontics is due to optimization of
the laboratory and chairside procedures together with
computerized arch wire fabrication and use of sophisticated materials.240 Customized brackets (Figure 14-38)
are produced after scanning the malocclusion model
from various perspectives, using a high-resolution optical
three-dimensional scanner. The brackets are designed
individually in the computer, are optimally positioned,
and subsequently are fabricated using computer-aided
design/computer-aided manufacturing technology. The
bracket bases have exact form-fit properties and later are
locked positively with the lingual surfaces of the teeth,
permitting direct rebonding should they come loose.
The bracket bodies of the customized brackets have a
lower profile than that of current prefabricated lingual
brackets (see Figure 14-37). The testing of various slot
types has shown a vertical slot with a vertical insertion
direction to be optimal (see Figure 14-38, B and C).
High-end rapid prototyping machines are used to
convert the virtual bracket series into a wax analog that
then is cast into hard alloy with high gold content. The
exact location of the bracket slots is known and transmitted to a bending robot through the export of slot
coordinate systems. The robot operates with two grasping tools and can bend arch wires precisely in highly
complex geometries. The superelastic arch wires are reprogrammed thermally during the actual bending process
to ensure precision manufacturing.240 This lingual technique can provide excellent treatment results with but
little (first-order) wire bending in the clinic.240,241
Rebonding
Figure 14-37
Lingual bracket bonding with seventh-generation Ormco
brackets. (Courtesy D Wiechmann, Bad Essen, Germany).
Bonded brackets that become loose during treatment consume much chair time, are poor publicity for the office,
and are a nuisance to the orthodontist. The best way to
avoid loose brackets is to adhere strictly to the rules for
good bonding mentioned previously. Use of a quick technique for rebonding loose brackets also is important.
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B
A
Figure 14-38
Customized brackets for lingual orthodontic treatment.
A to C, Digital setup with individually defined bracket
bases. (Courtesy D Wiechmann).
C
A loose metal bracket is removed from the arch wire.
Any adhesive remaining on the tooth surface is removed
with a tungsten carbide bur. The adhesive remaining on
the loose bracket is treated by sandblasting (see Figure
14-21) until all visible bonding material is removed
from the base. The tooth then is etched with Ultraetch
35% phosphoric acid gel for 15 seconds. On inspection
the enamel surface may not be uniformly frosty because
some areas still may retain resin. The phosphoric acid
will reetch any exposed enamel and remove the pellicle
on any exposed resin. After priming, the bracket is
rebonded. The neighboring brackets are religated first,
and then the rebonded bracket is ligated. The bond
strength for sandblasted rebonded brackets is comparable to the success rate for new brackets.206
A loose ceramic bracket should be replaced with a
new, intact bracket for optimum bond strength.
Recycling
Several methods of recycling debonded attachments
for repeat use, by commercial companies or by a duplicated procedure in office, are available.139 The main
goal of the recycling process is to remove the adhesive
from the bracket completely without damaging or
weakening the delicate bracket backing or distorting
the dimensions of the bracket slot. Recycling of brackets
has dropped off considerably over the past years
and now is done by only 4% of orthodontists in the
United States.128
Commercial processes use heat (about 450° C) to burn
off the resin, followed by electropolishing to remove the
oxide buildup (e.g., Esmadent), or they use solvent stripping combined with high-frequency vibrations and only
flash electropolishing (e.g., Ortho-Cycle). The electropolishing is needed for removal of any tarnish or oxide
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formed during the elimination of the adhesive from the
clogged pad.
Buchman42 published photomicrographs showing
microstructural changes after thermal treatment that
were correlated with a decrease in corrosion resistance
and hardness. Changes in torque angle and slot
size after one or two recyclings were below clinical
significance.42,107
Conclusion
Bonding of brackets has changed the practice of orthodontics and has become a routine clinical procedure in
a remarkably short time.128 Modifications of technical
devices, sealants and adhesives, attachments, and procedures are continuing. Careful study of the available
information by the orthodontist will be mandatory in
keeping up with progress. However, cautious interpretation of in vitro studies is recommended because the in
vivo results do not always reflect and verify the laboratory findings. Long-term follow-up studies are needed
in several areas.
At present the authors are using bonded brackets
routinely on all teeth except maxillary first molars. In
most routine situations, banding maxillary first molars
provides a stronger attachment and availability of lingual
sheaths (such as for transpalatal bars, elastics, and headgear) and may give some interproximal caries protection.
Finally, the procedure described for bonding mandibular second and third molars has proved to be successful
in clinical use over many years. This is particularly true
in adolescents, whose teeth are erupting during the course
of treatment. 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.
DEBONDING
The objectives of debonding are to remove the attachment
and all the adhesive resin from the tooth and restore the
surface as closely as possible to its pretreatment condition without inducing iatrogenic damage. To obtain these
objectives, a correct technique is of fundamental importance. Debonding may be unnecessarily time consuming
and damaging to the enamel if performed with improper
technique or carelessly.
Because several aspects of debonding are controversial,
debonding is discussed in detail as follows:
• Clinical procedure
• Characteristics of normal enamel
• Influence of different debonding instruments on
surface enamel
• Amount of enamel lost in debonding
• Enamel tearouts
• Enamel cracks (fracture lines)
• Adhesive remnant wear
• Reversal of decalcifications
Clinical Procedures
Although several methods have been recommended
in the literature for bracket removal and adhesive
cleanup,* and some discrepancy of opinion still exists,
the techniques described have proved successful in the
authors’ experience. Their rationales are mentioned
throughout the ensuing discussion.
The clinical debonding procedure may be divided in
two stages:
1. Bracket removal
2. Removal of residual adhesive
Bracket removal: steel brackets
Several different procedures for debracketing with pliers
are available. An original method was to place the tips
of a twin-beaked pliers against the mesial and distal
edges of the bonding base and cut the brackets off
between the tooth and the base. Several pliers are available for this purpose. A gentler technique is to squeeze
the bracket wings mesiodistally and lift the bracket off
with a peel force. This is particularly useful on brittle,
mobile, or endodontically treated teeth.
The brackets are deformed easily and are less suitable
for recycling when the latter method is used. The recommended technique, in which brackets are not
deformed, is illustrated in Figure 14-39. This technique
uses a peeling-type force, which is most effective in
breaking the adhesive bond. A peel force, as in peeling
an orange, creates peripheral stress concentrations that
cause bonded metal brackets to fail at low force values.165 The break is likely to occur in the adhesivebracket interface, thus leaving adhesive remnants on the
enamel. Attempts to remove the bracket by shearing it
off (as is done in removing bands) can be traumatic to
the patient and potentially damaging to the enamel.
Bracket removal: ceramic brackets
With the introduction of ceramic brackets a new
concern over enamel fracture and loss from debonding
has arisen.13,178 Because of differences in bracket
chemistry and bonding mechanisms, various ceramic
brackets behave differently on debonding. For example,
ceramic brackets using mechanical retention cause fewer
problems in debonding than do those using chemical
retention.32,178,231,245 In this regard, some knowledge
about the normal frequency, distribution, and orientation of enamel cracks in young and in older teeth is
important.
*References 41, 45, 54, 56, 104, 113, 167, 178, 181, 221, 262.
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Chapter 14 • Bonding in Orthodontics
613
B
A
Figure 14-39
Bracket removal with pliers. Still ligated in place, the brackets are gripped one by one with 095 Orthopli
bracket-removing pliers and lifted outwardly at a 45-degree 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. A, The bond breaks in the adhesive-bracket interface, and the pattern of the meshbacking is visible on the adhesive remaining on the teeth. B, Same technique for maxillary steel brackets.
Ceramic brackets will not flex when squeezed with
debonding pliers. The preferred mechanical debonding is
to lift the brackets off with peripheral force application,
much the same as for steel brackets (see Figure 14-39).
Several tie-wings still may fracture, which in practice
requires grinding away the rest of the bracket.178 Cutting
the brackets off with gradual pressure from the tips of
twin-beaked pliers oriented mesiodistally close to the
bracket-adhesive interface is not recommended because
it might introduce horizontal enamel cracks.
More recent ceramic brackets have a mechanical lock
base and a vertical slot that will split the bracket by
squeezing. Separation is at the bracket-adhesive interface, with little risk of enamel fracture.34
Low-speed grinding of ceramic brackets with no
water coolant may cause permanent damage or necrosis
of dental pulps. Therefore water cooling of the grinding
sites is necessary. High-volume suction and eye
protection also are recommended to reduce the number
of ceramic particles spread about the operatory area.234
Finally, thermal debonding32,66,122,188,211 and the use
of lasers140,183,225 have the potential to be less traumatic
and less risky for enamel damage, but these techniques
are still at an introductory stage.
Removal of residual adhesive
Because of the color similarity between present adhesives and enamel, complete removal of all remaining
adhesive is not achieved easily. Many patients may be
left with incomplete resin removal,83 which is not
acceptable. Abrasive wear of present bonding resins is
limited,41 and remnants are likely to become unesthetically discolored with time.
The removal of excess adhesive may be accomplished
by (1) scraping with a sharp band or bond-removing
Figure 14-40
Adhesive remaining after debracketing may be removed
with a tungsten carbide bur at about 30,000 rpm.
pliers or with a scaler251 or by (2) using a suitable bur
and contraangle (Figure 14-40). Although the first
method is fast and frequently successful on curved teeth
(premolars, canines), it is less useful on flat anterior teeth.
A risk also exists of creating significant scratch marks.
The preferred alternative262 is to use a suitable dometapered tungsten carbide bur (#1171 or #1172) in
a contraangle handpiece (see Figure 14-39). Clinical
experience and laboratory studies262 indicate that about
30,000 rpm is optimal for rapid adhesive removal without enamel damage. Light painting movements of
the bur should be used so as not to scratch the enamel.
Water cooling should not be used when the last remnants are removed because water lessens the contrast
with enamel. Speeds higher than 30,000 rpm using fine
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Part II • Techniques and Treatment
fluted tungsten carbide burs54,113 may be useful for bulk
removal but are not indicated closer to the enamel
because of the risk of marring the surface.104,113,262 Even
ultrafine high-speed diamonds produce considerable
surface scratches.113 Slower speeds (10,000 rpm and
less) are ineffective, and the increased jiggling vibration
of the bur may be uncomfortable to the patient.
When all adhesive has been removed, the tooth
surface may be polished with pumice54 (or a commercial
prophylaxis paste) in a routine manner. However, in view
of the normal wear of enamel, this step may be optional.
CHARACTERISTICS OF NORMAL
ENAMEL
Apparently not every clinician is familiar with the
dynamic changes that continuously take place throughout life in the outer, most superficial enamel layers.143,200
Because a tooth surface is not in a static state, the normal
structure differs considerably between young, adolescent, and adult teeth.143 Normal wear must be considered in any discussion of tooth surface appearance after
debonding. The characteristics are visible on the clinical
and microscopic levels.
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 (Figure 14-41). By scanning electron microscopy
the open enamel prism ends are recognized as small
holes.262 In adult teeth the clinical picture reflects wear
and exposure to varying mechanical forces (e.g., toothbrushing habits and abrasive foodstuffs). In other words,
the perikymata ridges are worn away and replaced by a
scratched pattern (Figure 14-42). Frequently, cracks are
visible. Scanning electron microscopy shows no evidence
of prism ends or perikymata; instead deep and finer
scratches run across the surface141,262 (Figure 14-43,
see also Figure 14-42). Teeth in adolescents reflect an
intermediate stage (see Figure 14-43). According to
*The use of the enamel surface terms perikymata and imbrications/
imbrication lines in the dental literature is inconsistent and confusing.
The present terminology is based on Risnes S: Rationale for consistency in the use of the enamel surface terms: perikymata and imbrications, Scand J Dent Res 92:1, 1984.
A
Enamel Prism Ends
B
C
Figure 14-41
A, Typical perikymata in a 10-year-old boy. B, Scanning electron microscopy appearance (×50.) C, Enlargement
of the central portion in B, showing numerous small pits (the typical signs of enamel prism ends) and a
crack. P, Perikymata.
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Chapter 14 • Bonding in Orthodontics
Horizontal Scratches
No Perikymats
No Prism Ends
FS
DS
A
B
DS
Figure 14-42
A, In adult teeth the perikymata remain in developmental grooves. Note the other irregularities: vertical and
horizontal scratches, pits, internal white spots, vertical cracks (B) (scanning electron micrograph, ×50).
Neither perikymata nor prism end openings are visible. However, note the severe horizontal scratches. Most
are fine (FS), but some are coarser and deeper (DS).
A
B
C
P
S
S
Figure 14-43
Scanning electron micrographs of normal enamel in young (A), adolescent (B), and adult (C) teeth. Note the
gradual transition from virgin tooth with perikymata (P) and open prism ends to a gradually increasing
scratched (S) appearance. (Scale division is 0.1 mm.) (B and C Courtesy F Mannerberg, Malmö, Sweden.)
615
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Part II • Techniques and Treatment
Green rubber wheel
Sand paper disk
A
B
TC-bur + pumice
(replica)
TC- bur
P
C
D
Figure 14-44
Comparison of the effect of three debonding techniques on the enamel surface. A to C, Scanning electron
micrographs after adhesive removal without subsequent polishing (×50). Note that the scratches are of similar
appearance in A and B but that in C only slight faceting with fine scratches (open arrows) is intermingled with
the perikyma ridges (P). D, Same area as in C in replica after pumicing. The surface is smoother (arrows).
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Chapter 14 • Bonding in Orthodontics
Mannerberg,143 at 8 years of age practically all teeth
show evident perikymata on one third to two thirds of
the tooth surface; at age 13, the number is reduced to
70% to 80%; and at age 18, only 25% to 50% of teeth
demonstrate such ridges. Using a replica technique to
study the gradual removal of artificial scratch marks on
the teeth, Mannerberg found the normal wear to range
from 0 to 2 µm per year. For comparison, a sandpaper
disk that touches the enamel only a fraction of a second
will leave scratch marks at least 5 µm deep.
Influence on Enamel by Different
Debonding Instruments
By proposing an enamel surface index with five scores
(0 to 4) for tooth appearance and using replica scanning electron microscopy and step-by-step polishing,
Zachrisson and Årtun262 were able to compare different
instruments commonly used in debonding procedures
and rank their degrees of surface marring on young
permanent teeth.
The study demonstrated that (1) diamond instruments
were unacceptable (score 4), and even fine diamond
burs produced coarse scratches176 and gave a deeply
marred appearance; (2) medium sandpaper disks
and a green rubber wheel produced similar scratches
(score 3) (Figure 14-44) that could not be polished
away; (3) fine sandpaper disks produced several
A
617
considerable and some even deeper scratches and a
appearance largely resembling that of adult teeth (score
2); (4) plain cut and spiral fluted tungsten carbide burs
operated at about 25,000 rpm were the only instruments that provided the satisfactory surface appearance
(score 1); however, (5) none of the instruments tested
left the virgin tooth surface with its perikymata intact
(score 0).
The clinical implication of the study is that tungsten
carbide burs produced the finest scratch pattern with
the least enamel loss and are superior in their ability
to reach difficult areas (Figure 14-45): pits, fissures, and
along the gingival margin. For optimal efficiency the
bur must be replaced when it becomes blunt. Increaseddiameter burs or high-speed equipment also may be
used for bulk removal.51,96
The oval tungsten carbide bur is useful for removing
adhesive remnants after debonding retainers and brackets
on the lingual surfaces of teeth.
Amount of Enamel Lost in Debonding
The orthodontic literature discusses how much enamel
actually is removed in routine bonding and debonding.
The amount is related to several factors, including the
instruments used for prophylaxis and debonding and
the type of adhesive resin used.73,176,221,232,262
An initial prophylaxis with bristle brush for 10 to 15
seconds per tooth (which is in fact much longer than
B
Figure 14-45
A, After debonding with a tungsten carbide bur at low speed. Gentleness of technique is reflected by the
evident perikymata-like pattern on debonded teeth (B). Same case as in Figure 14-63.
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Part II • Techniques and Treatment
that used in clinical routines) may abrade away as much
as 10 µm of enamel, whereas only about 5 µm may be
lost when a rubber cup is used.176,221
Cleanup of unfilled resins may be accomplished with
hand instrumentation only, and this procedure generally results in a loss of 5 to 8 µm of enamel. Depending
on the instruments used for prophylaxis, total enamel
loss for unfilled resins may be 2 to 40 µm.176,221
Adequate removal of filled resin generally requires
rotary instrumentation; the enamel loss then may be 10
to 25 µm. Pus and Way176 found that a high-speed bur
and green rubber wheel remove about 20 µm and a lowspeed tungsten carbide bur removes around 10 µm of
enamel. From in vitro micrometer measurements using
an optical system of a profile projector and steel reference markers, total enamel loss for filled resins was estimated to be 30 to 60 µm, depending on the instruments
used for prophylaxis and debonding.32,176,221 Additional
deep-reaching enamel tearouts down to a depth of 100
µm and localized enamel loss of 150 to 160 µm also
have been reported.73
However, using computerized three-dimensional
scanning over the tooth surface, van Waes et al.232
recently confirmed the authors’ observations of a more
limited loss of enamel when tungsten carbide burs are
used cautiously.262 Van Waes et al.232 found an average
enamel loss of only 7.4 µm and concluded that minimal
enamel damage is associated with careful use of a tungsten carbide bur for removal of residual composite.
In a clinical perspective the enamel loss encountered
with routine bonding and debonding procedures,
exclusive of deep enamel fractures or gouges resulting
from injudicious use of hand instrument or burs, is not
significant in terms of total thickness of enamel. The
surfaces usually bonded have a thickness of 1500 to
2000 µm. The claim that removal of the outermost layer
of enamel (which is particularly caries resistant and fluoride rich) may be harmful also is not in accordance
with recent views on tooth surface dynamics and with
clinical experience over many years. The facial tooth surfaces are left smooth and self-cleansing after debonding.
Caries have been demonstrated not to develop in such
sites even if the entire enamel layer is removed.
Similarly, no histologic or clinical evidence of adverse
effects was experienced after significant recontouring of
canines that had been ground to resemble lateral incisors as long as the surfaces were left smooth and sufficient water cooling was used.222,267 In that case, about
half the enamel thickness was removed.
Enamel Tearouts
Localized enamel tearouts have been reported to occur
associated with bonding and debonding metal73 and
ceramic brackets.178 Tearouts may be related at least in
part to the type of filler particles in the adhesive resin
used for bonding and to the location of bond breakage.
When comparisons were made between tooth surface
appearance after debonding metal brackets attached
with macrofilled (10 to 30 µm) or microfilled (0.2 to
0.3 µm) adhesives, a difference occurred when the resin
was scraped off with pliers.
Possibly small filler particles may penetrate into the
etched enamel to a greater degree than macrofillers may
penetrate. For instance, the holes corresponding to the
dissolved enamel prism cores in the central etch type
(see Figure 14-5, A) are 3 to 5 µm in diameter. On
debonding the small fillers reinforce the adhesive tags.
The macrofillers, however, create a more natural break
point in the enamel-adhesive interface. Similarly, with
unfilled resins there is no natural break point.
Ceramic brackets using chemical retention cause
enamel damage more often than those using mechanical
retention.32,178 This damage occurs probably because the
location of the bond breakage is at the enamel-adhesive
rather than at the adhesive-bracket interface.13,178
The clinical implications are (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 (see Figure 14-39, A)
and (2) to avoid scraping away adhesive remnants with
hand instruments.
Enamel Cracks
Cracks, occurring as split lines in the enamel, are common
but often are overlooked at clinical examination because
most are difficult to distinguish clearly without special
technique; generally they do not show up on routine,
intraoral photographs (Figure 14-46). Thus finger shadowing in good light or, preferably, fiberoptic transillumination is needed for a proper impression of the
crack268 (see Figure 14-46). The origin of cracks is multicausal. Different forms of mechanical and thermal
insult may fracture the enamel cap after eruption; this
results from the significant difference in rigidity between
enamel and dentin.
A distinct possibility is that the sharp sound sometimes heard on removal of bonded orthodontic brackets
with pliers is associated with the creation of enamel
cracks. The occurrence of cracks in debonded, debanded,
and orthodontically untreated teeth was discussed in a
study by Zachrisson et al.268 Using fiberoptic light technique, the researchers examined more than 3000 teeth
in 135 adolescents. The prevalence of cracks, their distribution per tooth, their location on the tooth surface,
and the type (pronounced versus mild, horizontal versus
vertical) were described. The most important findings
were that (1) vertical cracks are common (in fact, more
than 50% of all teeth studied had such cracks), but
individual variation is great; (2) few horizontal and
oblique cracks are observed normally; (3) no significant
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A
619
B
Figure 14-46
Enamel cracks generally are not visible on intraoral photographs. Several cracks clearly seen on the left
central incisor with fiberoptic transillumination (A) are undetectable by routine photography (B). Note the
vertical orientation of the cracks.
difference existed between the three groups regarding
prevalence and location of cracks; and (4) the most
notable cracks (i.e., those invisible under normal office
illumination) are on the maxillary central incisors and
canines.
The clinical implication of these findings is that if an
orthodontist (1) observes several distinct enamel cracks
on the patient’s teeth after debonding, particularly on
teeth other than maxillary canines and central incisors
or (2) detects cracks in a predominantly horizontal direction, this is an indication that the bonding or debonding technique used may need improvement. With ceramic
brackets, the risk for creating enamel cracks is greater
than for metal brackets. The lack of ductility may generate
stress in the adhesive-enamel interface that may produce
enamel cracks at debonding.13
Another clinical implication may be the need for pretreatment examination of cracks, notifying the patient and
the parents if pronounced cracks are present. The reason
for this examination is that patients may be overly inspective after appliance removal and may detect cracks that
were present before treatment of which they were
unaware. They may question the orthodontist about the
cause of the cracks. Without pretreatment diagnosis and
documentation (most cracks are not visible on routine
intraoral slides), proving that such cracks are indeed unrelated to the orthodontic treatment is almost impossible.
Abrasive wear depends on the size, type, and amount
of reinforcing fillers in the adhesive. When at the time
of debonding, varying amounts of adhesive purposely
were left on the teeth assumed to be the most exposed to
toothbrushing forces (i.e., the maxillary left canine and
one neighboring tooth), the abrasion over a 12-month
period was almost insignificant in clinical terms.41 Only
thin films of residual adhesive showed any reduction
in size.
The clinical implications of leaving residual adhesive
after debonding are not clear. Gwinnett and Ceen103
reported that small remnants of unfilled sealant did not
predispose to plaque accumulation and did begin to
wear away with time. However, this finding cannot be
transferred automatically to different types of filled adhesives, some of which have much greater wear resistance
and accumulate plaque more readily.263 The presence of
extremely thin films of adhesive may not be of esthetic
or other concern because any color change in the films
probably cannot be perceived. In some instances, to seal
surface irregularities such as pits and grooves may even
be advantageous to protect against demineralization.
Nonetheless, in light of Brobakken and Zachrisson’s
findings,41 it seems too optimistic to believe that residual filled adhesive will disappear quickly by itself after
debonding; it appears irresponsible to leave large accumulations of adhesive.
Adhesive Remnant Wear
Reversal of Decalcification
Frequently, adhesive has been found on the tooth surface, even after attempts to remove it with mechanical
instruments.45,56,73,104 Because of color resemblance to
the teeth, particularly when wet, residual adhesive easily
may remain undetected.83 In other instances, adhesive
may be left on purpose because the operator expects that
it will wear off with time.
White spots or areas of demineralization are carious
lesions of varying extent. The incidence and severity of
white spots after a full term of orthodontic treatment
have been studied by several authors.* The general conclusion was that individual teeth, banded or bonded,
*References 97, 153, 162, 269, 270, 271.
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A
B
Figure 14-47
Extreme degree of enamel demineralization after orthodontic treatment in a caries-prone patient (A). Note
that white spot lesions can occur on multiple teeth. B, The contour of the bonded brackets is visible on
several teeth.
may exhibit significantly more white spot formation than
may untreated control teeth (Figure 14-47). In a multibonded technique (with lack of any preventive fluoride
program), Gorelick et al.97 found that 50% of the patients
experienced an increase in white spots. The highest incidence was in the maxillary incisors, particularly the laterals. This obvious degree of iatrogenic damage suggests the
need for preventive programs using fluoride associated
with fixed appliance orthodontic treatment.
Extensive overviews of the different methods of
orthodontic fluoride administration have been presented.44,249 Daily rinsing with dilute (0.05%) sodium
fluoride solution throughout the periods of treatment
and retention, plus regular use of a fluoride dentifrice, is
recommended as a routine procedure for all orthodontic patients.249 The weak fluoride mouth rinse is effective yet has few risks, and most patients can manage to
use it easily for 1 to 2 years. Definite responsibility also
must be given to the patient to avoid decalcifications
during treatment. In addition, painting a fluoride varnish41 or new effective anticaries agents such as titanium
tetrafluoride47 over caries-susceptible sites at each visit
may be useful in patients with hygiene problems.
Much evidence now exists from in vivo and in vitro
studies to support the claim that small carious lesions
can heal, a process usually referred to as remineralization.18,164,199,200 Dental caries may not be a process of
simple continuing demineralization. Rather caries may
be the result of a dynamic series of events, with remineralization occurring naturally during the formation of a
carious lesion. Fluoride ions greatly enhance the degree
of remineralization (incorporation of calcium and phosphate from the saliva) and reduce the time required for
this mechanism to occur. Only lower levels of fluoride
are required to trigger the mechanism; raising the fluoride level further does not result in a greater degree of
remineralization.80,199 Other fluoride effects may be on
plaque adhesion (quantitatively and qualitatively),185
although the more traditional theory that fluoride
increases enamel resistance is probably not too significant. Thus fluoride ions may be concentrated into
demineralized areas, which thereby act as reservoirs
promoting remineralization from the saliva.
Although sufficient clinical evidence proves that the
process of white spot formation can be reversed at least
in part, more information is necessary before an optimal remineralization program for orthodontic patients
can be established.
Årtun and Thylstrup18 found that removal of the
cariogenic challenge after debonding results in arrest of
further demineralization, and a gradual regression of
the lesion at the clinical level takes place primarily
because of surface abrasion with some redeposition
of minerals. However, Øgaard et al.164 observed that
remineralization of surface softened enamel (such as
under a loose band or bracket from one visit to another)
and subsurface lesions are completely different processes.
The surface-softened lesions remineralize faster and more
completely than subsurface lesions, which remineralize
slowly, probably because of lesion arrest by widespread
use of fluoride. Visible white spots that develop during
orthodontic therapy therefore should not be treated
with concentrated fluoride agents immediately after
debonding because this procedure will arrest the lesions
and prevent complete repair. In the future, orthodontists can expect more effective methods for caries reversal to become available.47
At present it seems advisable to recommend a period
of 2 to 3 months of good oral hygiene but without fluoride supplementation associated with the debonding session. This procedure should reduce the clinical visibility
of the white spots. More fluoride may tend to precipitate
calcium phosphate onto the enamel surface and block
the surface pores, which limits remineralization to the
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A
621
B
Figure 14-48
White spot lesions before (A), and after (B), microabrasion. See text for details.
superficial part of the lesion, and the optical appearance
of the white spot is not reduced.
Microabrasion
When the remineralizing capacity of the oral fluids is
exhausted and white spots are established (Figure 14-48
see also Figure 14-47), microabrasion is the optimal way
to remove superficial enamel opacities. By the use of
this technique, one can eliminate enamel stains with
minimal enamel loss.
Clinical procedure: A custom-made abrasive gel is prepared with 18% hydrochloric acid, fine powdered pumice,
and glycerin. The active mixture is applied as follows94:
1. The gingiva is isolated using blockout resin or
rubber dam. Dental floss may be useful to prevent
soft tissue contact and injury from the acid.
2. The abrasive gel is applied using an electric
toothbrush for 3 to 5 minutes. The original
toothbrush tip is modified by cutting the peripheral
bristles to create a smaller brush tip to fit on tooth
surfaces better.
3. Rinse for 1 minute.
To prevent enamel pitting, the acid should not be left
on the tooth for an extended time. For best results, and
depending on the severity of the lesions, the procedure
can be repeated monthly 2 to 3 times. This makes stains
disappear gradually.
The microabrasion technique is effective in removing
white spots and streaks and brown-yellow enamel discolorations. In cases of more extensive mineral loss, however, grinding with diamond burs under water cooling
or composite restorations are inevitable.
BONDED RETAINERS
Permanent maintenance of the achieved result after
successful treatment of malocclusion is undoubtedly
a great, if not the greatest, problem for orthodontic
clinicians. This is especially true for adult patients.
Therefore the relative scarcity of literature on the subject
is surprising.
The use of fixed bonded retainers is increasing,128 and
the various forms allow more differentiated retention
than before. Bonded retainers also have other advantages:
1. Completely invisible from the front132
2. Reduced need for long-term patient cooperation
3. Long-term (up to 10 years) and even permanent
retention when conventional retainers do not
provide the same degree of stability
The term differential retention, as introduced by James
L. Jensen,117 implies that special attention is directed
toward the strongest or most important predilection
site for relapse in each case. Thus the most appropriate
mode of retention for the postorthodontic situation in
question should be used and should be based on a careful evaluation of the pretreatment diagnostic records,
habits, patient cooperation, growth pattern, and age.
Implicit in the introduction of the acid-etch technique
for direct-bonded retainers is the provision of a variety
of new methods for retention. This discussion reviews
the current level of technical expertise regarding bonded
retainers.
Because the technique is comparatively new, any
discussion of it is weakened by the evident lack of
published clinical and long-term research findings with
various types of retainers and splints.26 For this reason,
the discussion in a large part is based on the authors’
own experiences. The following subdivisions are used:
• Mandibular canine-to-canine (3-3) retainer bar
• Direct contact splinting
• Flexible spiral wire retainers
• Hold retainers for individual teeth
In the following pages, two different types of retainer
wire are discussed—a thick one (0.030 or 0.032 inch)
and a thin one (0.0215 inch)—with entirely different
indications and modes of bonding.
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A
B
C
D
Figure 14-49
A, First-generation bonded mandibular lingual 3-3 retainer. B, Second-generation 3-3 retainer. C and
D, Third-generation 3-3 retainer in stainless steel and gold-coated bar, respectively.
Bonded Lingual Canine-to-Canine
Retainer Bar
Lingually bonded 3-3 retainers can provide excellent
results11,16,26,31,252 (Figure 14-49) if meticulous construction and bonding techniques are followed, along with
some modifications of the original design.
In differential retention philosophy the purpose of a
bonded 3-3 retainer bar is (1) to prevent incisor recrowding, (2) to hold the achieved lower incisor position in
space, and (3) to keep the rotation center in the incisor area
when a mandibular anterior growth rotation tendency is
present. The retainer bar may be indicated particularly in
persons with a flat functional occlusal plane,117 open bite,
Class II with rotation center in the premolar area (Björk’s
anterior rotation Type III36), or Class III growth tendency.
The standard appliance is bonded to the lingual surfaces of the canine teeth. The bar, which originally was
constructed from plain blue Elgiloy wire with a loop at
each terminal end for added retention252 (see Figure
14-49, A) was replaced by a similar-diameter multistrand
wire (see Figure 14-49, B). For some patients, this wire
proved not solid enough and distorted, and the wire
was difficult to bend to optimal fit. These drawbacks are
eliminated in the third-generation design (see Figure
14-49, C and D), in which the bar is made from round
0.032-inch stainless steel or 0.030-inch gold-coated
wire,259 sandblasted on the ends for improved micromechanical retention. Bonding is done with a chemically
or light-cured composite resin because such adhesives
provide the strongest bonds257and show comparatively
little abrasion over extended periods.27,41
In selected cases when the lower first premolars at the
start of treatment are blocked out labially, severely
rotated, or tipped, extention of the 3-3 bar to include
also the first premolars (43-34 retainer) is useful. This is
done simply by adding and bonding a small piece of thin
wire between the premolar and canine (Figures 14-50
and 14-51). The 43-34 design also may be used when
after orthodontic leveling of the six anterior mandibular
teeth the orthodontist desires to prevent their reerupting above the functional occlusal plane.
Some companies supply preformed lingual 3-3 retainers with bonding pads. These may be more difficult to
fit and bond tightly. At the same time, obtaining maximal contact on the lingual surfaces of all four incisors
also may be more difficult.
Failure analysis
Initial failures with first-generation bonded lingual 3-3
retainers were classified into two types.252 Type I failure
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Chapter 14 • Bonding in Orthodontics
A
623
B
Figure 14-50
A, A 43-34 retainer can be used when the first premolars are blocked out labially or tipped mesially
pretreatment. B, The 0.030-inch 3-3 retainer bar is extended by means of a thin (0.0215-inch coaxial) goldcoated wire between the canine and first premolar.
B
A
Figure 14-51
A, Adult patient with pretreatment blocked-out right second and left first premolar treated with extraction of
the second premolar on the right side. B, Final result is retained by means of a short labial gold-coated
retainer in the closed extraction site and a 3-34 retainer.
was related to separation at the tooth-adhesive interface
and occurred with the highest frequency. Type I failure
most commonly resulted from moisture contamination
or movement of the lingual bar during the initial polymerization of the composite. Type II failure occurred at
the adhesive–retainer wire interface and resulted from
inadequate bulk of adhesive for sufficient strength (or
abrasive wear of the adhesive). An important note is that
with adequate technique, one can avoid both types of failure.
In other words, a clinician who experiences discouraging
failure rates should reevaluate and improve the technique of making bonded lingual retainers.
Lingual retainer adhesives
Different composite resins have been advocated for bonding retainer wires.26 Unlike the adhesive under a bracket,
the lingual retainer resins remain exposed to the oral
cavity and therefore require some specific physical properties. Several specific lingual retainer adhesives may offer
ease of application, optimal handling, improved patient
comfort, and minimal abrasive wear. Recent findings228
indicate that light-activated composites may have these
properties. The amount of total light energy delivered to
the composite resin determines hardness,21,81,187 wear
resistance,82 water absorption,171 residual monomer171 and
its biocompatibility.57 Recent studies have tested the surface hardness228 and conversion rate230 of some different lingual retainer adhesives. Two light-cured adhesives
(Transbond LR, 3M/Unitek; and Light Cure Retainer,
Reliance Orthodontics) were cured with conventional
halogen (Ortholux XT), fast halogen (Optilux 501), and
plasma arc (PowerPac, American Dental Technologies,
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Part II • Techniques and Treatment
Corpus Christi, Texas) light sources and were compared
with autopolymerizing diluted or undiluted Concise
resin.70 The following conclusions emerged:
1. Plasma arc and fast halogen lights are quicker
alternatives than conventional halogen lights
without compromising final hardness values of
the lingual retainer adhesives.
2. Some adhesives may need unexpectedly long curing
times with fast curing lights (Light Cure Retainer
with PowerPac in this study).
3. Transbond LR yielded significantly higher surface
hardness than Concise and Light Cure Retainer,
with Concise being significantly harder than Light
Cure Retainer.
4. The dilution of Concise resin decreased the in vitro
surface hardness, which in turn may decrease its
clinical abrasion resistance and longevity.
The authors’ ongoing clinical study on lingual retainers
bonded with a split-mouth design using Transbond LR
on one side and diluted Concise on the other so far has
demonstrated equal and excellent success rates. After
2 years, only one bond failure occurred in the Concise
group. The heat caused by rapid curing with high-intensity
lights160 and shrinkage of the composite resin138 probably are of little clinical concern for the small amount of
resin used when bonding lingual retainers.
Bonding 3-3 retainer bar with chemically
cured composite resin
The following clinical recommendations (Figure 14-52)
represent the authors’ present approach. The basic principles have been tested clinically over several years.
Although it may seem possible to take shortcuts, this is strongly
discouraged; strict adherence to a meticulous technique
has been found to be the key to long-term success.
The clinical procedure with a two-paste chemically
cured composite resin is as follows:
1. While the orthodontic appliances remain in place,
take a snap impression of the patient’s teeth and pour
a working model of hard stone (plaster is inadequate
because it may abrade during wire fabrication, and
then the retainer will not fit in the mouth).
2. 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 pliers so that the wire precisely
contacts the lingual surface of all mandibular
incisors (see Figure 14-52, A and B).
3. Sandblast the ends with 50-µm aluminum oxide
powder for about 5 seconds from different directions,
using the Microetcher (see Figure 14-52, B) in a dust
cabinet.
4. Clean the lingual surfaces of both canines with a
tungsten carbide bur (#7006).
5. Check the position of the wire in the mouth. When
optimal, fix with three or four steel ligatures around
6.
7.
8.
9.
10.
11.
the bracket wings of the incisors
(see Figure 14-52, C and D).
The high lingual saliva evacuator–bite
block–tongue holder provides a dry working field
with good overview (see Fig 14-52, C). One to
three cotton rolls can be placed in the labial lower
incisor region (but the lip expander is not used).
With retainer wire in place, etch the lingual
surfaces of the canines with colored phosphoric
acid gel (Ultraetch 35% or Etch-Rite 38%
[Pulpdent];) (see Figure 14-52, E) for 30 seconds.
Rinse and dry completely. Use a high-speed
vacuum evacuator. Sealant is not needed on
lingual surfaces, partly because of the reduced risk
of decalcification. This fast and efficient procedure
reduces the risk of moisture contamination.
Bond the retainer using a two-step procedure:
a. Tacking: Tack the wire to both canines with a
small amount of a flowable light-cured
composite resin (e.g., Revolution, Kerr) and cure
for 5 seconds (see Figure 14-52, G). This initial
tacking is vital for strength. Because the wire
now cannot be displaced, the bulk of adhesive
can be added with a totally undisturbed setting.
b. 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.257
Check with a mouth mirror to see that enough
adhesive is used, and add more composite resin
wherever required (often in the mesiogingival and
distogingival corners). Having enough adhesive in
the mesiodistal and incisogingival directions is
important (see Figure 14-52).
Trim along the gingival margin and contour the
bulk with an oval tungsten carbide bur (#7408; see
Figure 14-52, I) so that it has a smooth contour in
an incisogingival direction. Use a smaller bur (#2)
interdentally.
Instruct the patient in proper oral hygiene and use
of dental floss or Superfloss (Oral-B, South
Boston, Massachusetts) beneath the retainer wire
and along the mesial contact areas of both canines
(Figure 14-53). Instruct patients to floss once daily
to prevent accumulation of calculus and plaque.
Bonding 3-3 retainer bar with light-cured
composite resin
When using a light-cured composite resin (i.e., Transbond
LR), the previous steps 1 to 7 are identical. The procedure
continues as follows:
8. Following the rinse and drying, use a fine brush
and apply a thin coat of moisture insensitive primer
(Transbond MIP) on the sandblasted ends of the
retainer wire and on the etched enamel. This will
reduce the risk of moisture contamination.
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A
B
C
D
E
F
G
H
Figure 14-52
Making the bonded 3-3 retainer bar. A, Careful adaptation of retainer wire on stone model using fine threejaw pliers. B, Sandblasting terminal ends of retainer bar. C, Lingual saliva ejector with high bite block
(3M/Unitek) secures an optimally dry working field with no interfacing appliances. D, The 0.030-inch goldcoated wire is positioned by means of three steel ligatures. E, Ultraetch 35% phosphoric acid gel for acid
etching. F, Treated area clearly indicated. G, Initial tacking with small amount of flowable light-cured composite resin. H, Bulk of adhesive added to tacked retainer.
Continued
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Part II • Techniques and Treatment
I
J
Figure 14-52, cont’d
I, Trimming adhesive with #7408 tungsten carbide bur. J, Final appearance.
A
B
Figure 14-53
Interdental cleaning under a bonded 3-3 retainer. A, If a floss threader is not available, a loop is formed over
two incisors and moved under the retainer bar. B, When one end of the floss is pulled in, the other will snap
free and can be grabbed with the fingers. Patients are instructed to move the floss over the interproximal
surfaces once daily.
9. Using the adhesive dispensing barrel and capsules,
apply the Transbond LR adhesive to the right and
left canines. Shape the resin bulk with fine brush
strokes from the gingival margin to the incisal
edge. A small amount of Transbond MIP on the
brush tip will dilute the composite resin and make
it flowable, and this will create a smooth, gentle
contour in an incisogingival direction. It takes
some experience to find the right consistency. If
too much primer is added, the adhesive will drift
away from where it is placed and may flow
interdentally and contact the gingiva. Optionally,
the adhesive may be transferred from a mixing
pad. The adhesive on the mixing pad should have
a light-impermeable cover.
10. Same as the previous step 9.
11. Light cure the composite resin according to
instructions for light source used (e.g., 5 seconds
with the plasma arc light or 40 seconds with
conventional halogen light). Cut the ligature
wires.
13. Same as the previous steps 10 (trim whenever
necessary) and 11.
Long-term experience
Experience with bonded 3-3 retainer bars over 10 to
15 years is generally excellent, provided careful bonding
technique is used.17,26,253,254,257 Particularly, the third-generation 3-3 retainer is a fine mandibular retainer. Not only
is the retainer solid, easy to place, and hygienic, but also it
appears to be safer than mandibular retainers in which all
six anterior teeth are bonded, which is equally important.
A patient notices immediately whether a retainer comes
loose when it is bonded only to the canines. The patient
then can call for a rebonding appointment to remove the
retainer if necessary. For several years, a mandibular bar
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Chapter 14 • Bonding in Orthodontics
TABLE 14-1
627
Hierarchy of Success Rate for Different Types of Bonded Lingual Retainer
Type of Retainer
Wire Diameter
Mandibular 3-3
Mandibular 321-123
Maxillary 21+12
Maxillary 321+123
0.030 inch
0.0215 inch
0.0215 inch
0.0215 inch
Number of Patients
Success Rate
(No Loosening or Wire Breakage)
381
191
323
186
96.5%
94.7%
93.8%
78.5%
Data refer to gold-coated retainers bonded from May 1994 to May 2004. Mean observation time is 4.2 years (range 1 to 10 years). Success rate refers
to intact retainers (without bond failure or wire fracture) throughout the follow-up period. All retainers were bonded in the same office by one orthodontist (B Zachrisson).
bonded only to the canines has been the authors’ preferred retention method in adolescent and many adult
patients. However, occasional cases of slight relapse anteriorly may occur when using retainers bonded only to the
canines.17 For this reason, an flexible spiral wire (FSW)
retainer bonded to all six anterior teeth (see the following
discussion) may be indicated for adult patients with considerable pretreatment crowding.
The senior author’s long-term (up to 7 years) experience with third-generation stainless steel and gold-coated
3-3 retainer bars show excellent outcomes with few
loosenings (Table 14-1). The failure rates are considerably lower than those reported by others,16,26 which
probably is explained by careful bonding procedure
(see Figure 14-52). Some initial problems with corrosion caused by microleakage around the gold-plating
have made it advisable to extend the sandblasting
slightly beyond the area of composite bonding (see
Figures 14-50 to 14-52).259
Many patients apparently have difficulties keeping
the retainer area really clean, despite patient instruction
in hygiene. Accumulations of supragingival calculus and
stain often are noted along and beneath the retaining
wire,106 whereas decalcification and caries are observed
only exceptionally.17,26,97 Clinical data indicate no significant difference in plaque and calculus accumulation
between round and spiral retainer wires.11,16,17 However,
the presence of even large amounts of calculus around
mandibular retainers is not alarming in young, healthy
patients with no periodontal pockets.89,238 Gaare et al.89
compared the effect of toothbrushing after professional
prophylaxis in patients with large amounts of calculus
(removal requiring an average time of 1 hour per
patient) with the effect of toothbrushing as the sole
hygiene method. The authors found no significant
benefit of the calculus removal, which supports the
hypothesis that it is not the calculus but the plaque that
forms on it that has pathogenic potential. The effects of
calculus accumulations on retainers in adults with existing periodontal problems are unknown at present.238
Because the retainers are invisible, a problem may exist
in deciding when to remove them. Extended retention
periods (up to 10 years) now are recommended by most
clinicians.30,98,190,259 For adolescent patients, Behrents30
recommended retention into the mid-20s for males and
until the early 20s for females. The long retention
periods are favorable in many patients while waiting for
the patient’s third molars to erupt259; long retention
counters the effects of postpubertal growth activity and
maxillomandibular adjustments,30 which may continue
well into the second decade and longer.30,259 As an alternative, the bonded retainer may be replaced after several
years with a removable one for long-term or permanent
nighttime wear.
Direct Contact Splinting
In the late 1970s several preliminary and short-term clinical reports were published on direct contact splinting
of segments of teeth. The reports appeared mostly in
the orthodontic and periodontic literature and represented attempts to prevent postorthodontic space
reopening between teeth and provide stability against
traumatic jiggling (so-called periodontal splints). A
variety of techniques and adhesive resins were used.186
Although some degree of clinical success was experienced, follow-up results indicated a high percentage of
bond breakage.14,186,210,250
Bond breakage was illustrated clearly in some experiments on postorthodontic splinting (Figure 14-54).
Careful technique involved the use of rubber dams for
moisture control, toothpicks to avoid interdental flow
of adhesive, and bonding adhesive applied in a wide
incisogingival area. A number of clinical situations
calling for specific retention were addressed, using two
different restorative-type composite resins and one lightpolymerized sealant.250 The results were consistently discouraging; breakage or fracture of the adhesive occurred
within a few weeks or months whenever segments larger
than two teeth were splinted.
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Part II • Techniques and Treatment
A
B
C
D
Figure 14-54
Direct contact splinting. A, Working field with rubber dam, toothpicks, dental floss, and clamp. B, Contact
splint using light-cured sealant. Note the wide contact area in the apicoincisal direction. C, Break after
2 months of splinting. D, Breaks in mandibular canine-to-canine splint where composite resin was used.
Dental floss is inserted to show location of the failures. Note that the splint broke into segments of one or
two teeth.
These results are in clear contrast to the authors’
experience with the FSW retainers. The apparent reason
for the bond breakage is the need for independent physiologic
tooth movement during function. Unfortunately, the rigidity of the contact splints does not facilitate individual
tooth movements and therefore is not recommended as
a mode of bonded retention.
Based on the foregoing and other studies, one generally can state that contact splinting without some form
of wire reinforcement should not be considered a
method of choice.
When contact splinting on pontics is used for missing maxillary lateral incisors or to hide empty spaces
after extractions of premolars or lower incisors in adults,
reinforcement of the splint with a small piece of braided
wire is recommended (Figures 14-55 to 14-57). If the
splint breaks, the wire will keep the pontic in position.
Flexible Spiral Wire Retainers
Clinical experience and differential retention philosophy have demonstrated the need for two types of bonded
wire retainer:
1. Thick wire (0.030- or 0.032-inch diameter)
2. Thin wire (0.0215-inch diameter)
The thick wire is used for the mandibular 3-3 retainer
bar bonded on the terminal dental units only, whereas
the thin spiral wire is used for various retainers in which
all teeth in a segment are bonded.
In discussing the FSW retainer, the following subdivisions are used:
1. Advantages and disadvantages
2. Long-term experience
3. Technical procedure
4. Repair
5. Indications
6. Conclusions and clinical recommendations
In 1977 the authors’ results indicated that bonded
retainers using thin multistrand flexible wire (0.015to 0.020-inch diameter) appeared to be suitable for
preventing space reopening in different clinical situations.252 Long-term (up to 15 or more years) results
are now available for different wire types (see Table 14-1),
verifying that the combination of thin spiral wire
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Chapter 14 • Bonding in Orthodontics
A
629
B
Figure 14-55
A, Missing lateral incisor case where an acrylic pontic was direct splinted to the central incisor during the
orthodontic treatment. B, Note braided rectangular wire reinforcement.
A
B
Figure 14-56
A, Direct contact splinting of extracted mandibular left central incisor in an adult woman (B), where the
protruding lower incisors had caused multiple spacing of maxillary incisors.
with wear-resistant bonded composite can provide a
useful mode of retention for a variety of postorthodontic situations70,253,254,255,258 (Figure 14-58).
Advantages and disadvantages
Flexible spiral wire retainers have several 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, the possibility remains of hiding
the wire under a slight groove in the enamel.
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Part II • Techniques and Treatment
A
B
Figure 14-57
A, Direct contact splinting of acrylic pontic to hide the premolar extraction spaces in an adult male
patient concerned not to show empty spaces. B, Both contact splints were reinforced with a braided
rectangular wire, which kept the pontics in place during the canine retraction period despite resin
fracture in both contact points. The pontics were ground on the distal surfaces to accommodate to the
space conditions.
6. They can be used alone or with removable
retainers.
However, FSW retainers have some disadvantages.
Good oral hygiene of patients is mandatory. Daily
flossing in each interdental space is recommended
with the use of a dental floss threader or Superfloss gingival to the wire. The gingival reaction of course also
depends on careful removal of excess adhesive at the
time of retainer bonding.254 Side effects in the form of
undesirable movement of bonded teeth may occur if
the wire is too thin or not entirely passive while bonding.18,70 Finally, FSW retainers are more subject to
mechanical stress and are thus less indicated in deep
overbite cases when the wire cannot be placed out of
occlusion.19
Long-term experience
Experiments in the late 1970s and early 1980s used different sizes (0.015- to 0.020-inch diameter) and types of
multistranded wires.252,254,256 Early findings included
the following:
1. The incidence of wire breakage appeared to decrease
with increasing wire diameter.
2. Undesirable side effects and tooth movements
occurred when short segments of 0.015-inch wire
were used.
3. An unacceptable incidence of bond failures occurred
when the wires were bonded to the lingual surfaces
of premolars.251,252,256
Bond failures and other clinical features of lingually
bonded retainers were reported in 1991 by Dahl and
Zachrisson.70 The observation periods were then an average of 6 years for maxillary and mandibular 0.0215-inch
three-stranded wire* and 3 years for the same diameter
five-stranded wire.
The failure rates were considerably lower than those
reported in other recent studies of lingual retainers over
periods of 2 to 3 years.17,19,26 The results with the fivestranded Penta-One wire (Masel Orthodontics, Bristol,
Pennsylvania) were particularly encouraging. The failure rates for loosening were 8% in the maxilla and
6% in the mandible; for wire fracture the failure rates
*Tri-Flex wire (Rocky Mountain Orthodontics, Denver, Colorado) and
Wildcat wire (GAC International).
Graber-Ch-14 28/9/04 12:34 AM Page 631
A
B
C
D
E
F
G
H
Figure 14-58
Four different clinical situations in which a lingual flexible spiral wire retainer is used for improved retention. The cases represent significant midline diastema of maxillary central incisors (A and B), bilaterally missing maxillary lateral incisors (C and D), one lower incisor extraction in Class III plus open-bite tendency case
(E and F), and two palatally impacted maxillary canines (G and H). In D the six-unit retainer is bonded in
the occlusal fossa of the first premolars, whereas in H a short labial retainer is used bilaterally to stabilize the
mesially rotated and palatally displaced canines and the distally rotated first premolars.
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Part II • Techniques and Treatment
were 3% in the maxilla and were nonexistent in the
mandible.70
Since May 1994 the senior author has used a goldplated version (Gold’n Braces) of the five-stranded
Penta-One wire exclusively and has observed few failures (see Table 14-1). The mechanical properties of the
stainless steel and gold-coated wires are identical, but
the latter is preferred because it is (1) more elegant and
(2) gives less darkening shine-through effect on transparent incisors.
The discrepancies between the authors’ experience
and that of other studies probably can be explained by
fewer occlusal interferences (with less contact with
opposing teeth to allow for more wear) and by technical factors (such as adequate buccolingual width of
composite over the wire, smooth contouring of the
adhesive, completely undisturbed setting of the adhesive in every case, and careful adaptation of the wire to
the lingual contours of the teeth). The reduction of wire
breakage compared with earlier results is related to the
increased flexibility of five smaller wires occupying the
same diameter as the three larger wires in previous
retainers. Because a common mode of failure with
bonded FSW retainers is abrasion of composite and
subsequent loosening of bonds between wire and composite,19 one is advised to avoid occlusal contact or to
add a thick layer of adhesive over the wire. Even in the
absence of tooth contact, such as in the mandible,
mechanical forces (tongue activity, toothbrushing) may
cause notable abrasion over the years.
Patient acceptance of the FSW retainer is excellent.23,70 In addition, adults especially appreciate
that the stability of the treatment result does not
depend on their cooperation, which is the case when
removable retainers are worn continuously or are
worn at night.
When patients with previous multiple spacing
of anterior teeth were in the retention phase of treatment, it often was found that after about 6 months
small spaces (1 to 2 mm) opened distal to the terminal
ends of the retainer wire. Because these spaces apparently did not open further, it was concluded that they
illustrated a settled occlusion with the FSW retainer in
place in a new state of physiologic equilibrium.23,70,252
Depending on the occlusion and the patient’s dental
awareness, such spaces could be filled with mesiodistally extended fillings or crowns or could be allowed
to remain.
At present, little is known about the length of
time that the bonded FSW retainer should be left in
place. The type of original malocclusion and the
patient’s age and ability to keep the retainer clean
may be decisive factors. As long as the retainer is
intact, the treatment result is maintained; and as long
as the patient performs adequate plaque control,
no real reason exists to remove the retainer.
Accumulations of calculus in mandibular FSW
retainers may not be alarming.17,89,231 In selected
cases retainers may be used for permanent stabilization
(see Chapter 27). Advanced periodontal cases probably
also need permanent retention (see Figure 14-59).
Further follow-up research is needed for semipermanent and permanent use of bonded retainers. As discussed for the 3-3 retainers, in some cases it may
be practical to use the bonded lingual retainer for a
prolonged retention period and then to replace it
with a removable retainer for nighttime wear on a more
permanent basis.
Bonding flexible spiral wire retainer with
chemically cured composite resin
Based on clinical experience with the FSW retainer over
the past 20 years, the following clinical direct-bonding
procedure is advocated for its fabrication and bonding70
(Figure 14-60):
1. Toward the end of orthodontic treatment, take
a snap impression and pour a working model
in stone.
2. Using fine, three-pronged wire-bending pliers and
marking pen, adapt the 0.0215-inch Penta-One steel
or gold-coated wire (Gold’n Braces) closely and
passively to the crucial areas of the lingual surface
of the teeth to be bonded. Cut the wire to the
required length.
3. When making a maxillary retainer, tilt the patient
into a horizontal position to allow direct view and
facilitate working on the lingual aspects of the
incisors (Figure 14-61).
4. Check the retainer wire in the mouth for good fit in
an entirely passive state and adjust if necessary.
5. Clean the surfaces to be bonded with a tungsten
carbide bur180,257 and etch with phosphoric acid gel
(Ultraetch or Etch-Rite) (Figure 14-62; see also
Figure 14-60) for 30 seconds.
6. Use a four-handed approach (or similar) for
initial tacking (see Figure 14-60, C, and 14-63, B).
Hold the wire by hand in the optimal position
while tacking it to one incisor with a small
amount of flowable light-cured composite resin
(e.g., Revolution). Check the wire for passive
tension after tacking (see Figure 14-62, E).
If the wire is passive, tack the remaining teeth;
if not, remove the wire and start over.
7. The initial tacking (see Figure 14-60, E) is vital
to securing wire passiveness and optimal bond
strength because the tacked wire cannot be
displaced and cause disturbed setting when the bulk
of adhesive is added. Check with a mouth mirror to
be sure that enough adhesive is used. Add more
adhesive whenever it is required. That the adhesive
cover a large buccolingual area over the wire is
important for strength.
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Chapter 14 • Bonding in Orthodontics
A
C
B
D
Figure 14-59
Adult female patient with advanced hard and soft periodontal tissue destruction and pathologic migration
of the maxillary anterior teeth before (A to E), during (F), and after (G to J) orthodontic treatment. The
improved dental result is retained by means of six-unit bonded lingual retainers in both dental arches (H and I).
Some interdental gingival recession was unavoidable in the maxillary anterior region, but it does not show
much clinically (J). The radiographs after treatment showed no progression of periodontal tissue destruction
compared with the initial films (C).
Continued
633
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Part II • Techniques and Treatment
E
F
G
H
I
J
Figure 14-59, cont’d
For legend see p. 633.
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Chapter 14 • Bonding in Orthodontics
635
A
B
C
D
E
F
Figure 14-60
Fabrication of four-unit flexible spiral wire retainer with chemically cured composite resin. A gold-coated
Penta-One wire is adapted carefully on a model with fine three-jaw pliers to fit the lingual contours of the
incisors passively. A and B, Acid etching of the lingual surfaces of the upper incisors. C and D, The initial
tacking to one incisor is made with flowable light-cured resin, with the wire held in the optimal position by
a finger. This initial tacking to one tooth allows direct checking of position and fit of the retainer wire and is
the key to avoid unwanted tooth movement as a side effect during the retention period. When correct and
passive, the remaining teeth are tacked next with a small amount of light-cured flowable resin (E) before the
bulk of adhesive is added in a gingival-occlusal movement (F).
Continued
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Part II • Techniques and Treatment
G
H
I
J
Figure 14-60, cont’d
A thin mix of composite resin then is added with an explorer to fill in the bond mesially and distally on each
tooth. Trimming is made with tungsten carbide burs (G to I). The #7006 bur is ideal incisal to the wire to
avoid occlusal interference, whereas the contour gingival to the wire is made with the #7408 bur. J shows the
final result.
8. Contour the bulk of adhesive and remove any
excess along the gingival margin. Use oval
tungsten carbide burs (#7006 and #7408) to
obtain correct amount and contour of adhesive
(see Figure 14-60, G and H), and remove adhesive
interdentally with small, round burs (#1 and #2;
see Figure 14-60, I)
9. Instruct the patient in proper oral hygiene and use
of dental floss and in each interdental area with a
floss threader or Superfloss.
Bonding flexible spiral wire retainer
with light-cured composite resin
When using a light-cured composite resin (e.g.,
Transbond LR), follow the foregoing procedure for
steps 1 to 5 (see Figures 14-62 and 14-63). The procedure continues as follows:
6. Use a four-handed approach (or similar) for the
initial tacking. Hold the wire by hand in the
optimal position while tacking it to one incisor
with a small amount of Transbond LR
(see Figure 14-62, B). Check the wire for passive
tension after tacking. If the wire is passive,
add more adhesive and light cure the remaining
teeth; if it is not, remove the wire and start
over again.
7. Contour the bulk of adhesive with the brush
dipped into the primer (Figure 14-61, D).
Optionally, transfer the adhesive from a mixing
pad, which should have a light-impermeable
cover. That the adhesive cover a large labiolingual
area over the wire is important for the strength
and wear resistance. Trim with burs when necessary.
8. Same as the previous step 9.
Indirect bonding of flexible spiral wire retainer
The fixed lingual retainer also can be fabricated with an
indirect technique as described elsewhere.24,28,125 A practical approach for lingual retainers is to use indirect
bonding with a 2-mm thick polyethylene thermoplastic
transfer tray and Transbond LR and Sondhi Rapid Set as
adhesive resins.125
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Chapter 14 • Bonding in Orthodontics
637
A
B
C
D
Figure 14-61
A, Working position when making a bonded retainer in the maxilla. B, Tacking. C, Adding composite resin.
D, Trimming.
Repair
Indications
The most common problem following wire fracture or
the loosening of the bonding site(s) in FSW retainers is
unwanted movement of one or more teeth. At this stage,
the teeth are not seated firmly in their sockets and therefore generally can be forced back into position using
techniques such as heavy pull with one or two steel
ligatures (Figure 14-64, A and B).
When the repair is made, a temporary contact \splint
using composite resin or a temporary bonded labial
wire have proved to be of considerable value. The latter
normally provides better stability and allows a good
working area with undisturbed setting of the repair
adhesive (Figure 14-64, C and D). After the repair the
temporary labial wire (or contact splint) is removed
with tungsten carbide burs.
At least two indications or suggestions are useful for using
bonded FSW retainers:
1. Prevention of space reopening
a. Median diastemas
b. Spaced anterior teeth
c. Adult periodontal conditions with the potential
for postorthodontic tooth migration
d. Accidental loss of maxillary incisors requiring
the closure and retention of large anterior spaces
e. Mandibular incisor extractions
2. Holding of individual teeth
a. Severely rotated maxillary incisors
b. Palatally impacted canines
In these and other situations the bonded thin spiral
wire retainer can be used alone or with a removable
Graber-Ch-14 28/9/04 12:35 AM Page 638
A
B
C
D
E
F
G
H
Figure 14-62
Instruments (A) and method (B to G) for fabrication of six-unit lingual flexible spiral wire retainer with lightcured composite resin. After an 0.0215-inch stainless steel or gold-coated Penta-One wire is adapted for
optimal fit on the lingual surfaces of all teeth (B), the teeth are acid etched with phosphoric acid gel (C).
Composite resin is added to one incisor (D and E) and light cured. After a check that the wire is passive and
has a good fit to the remaining teeth, composite resin is added, shaped with the aid of liquid resin and fine
brush (F), and is light cured (G). H shows the final result.
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Chapter 14 • Bonding in Orthodontics
639
A
B
C
D
Figure 14-63
Fabrication of four-unit flexible spiral wire retainer with light-cured composite resin. A, Etching with phosphoric acid. B, Finger-holding of wire while tacking one incisor. C, Light curing the remaining teeth. D, Final
result. See text for details.
retainer. Some details of specific interest relative to the
retention in this list of treated malocclusions are discussed briefly.
Closed Median Diastemas. The bonded FSW
retainer is ideal for short- or long-term retention of
closed median diastemas. The 0.0215-inch five-stranded
wire should be bonded preferably over four units
(Figures 14-65 and 14-66) to reduce the risk of untoward side effects.70,254
Multiple Spacing of Anterior Teeth. Unimaxillary
or bimaxillary spacing of teeth in adolescents and adults
is generally easy to treat but difficult to retain. The tendency for space reopening may be great, even despite
long periods of retention with conventional appliances.
For this reason, a number of experimental approaches
have been reported recently, including the use of
splints,76 staples,60,63 and mesh.93,186
None of these methods seems to have gained a wide
acceptance, however. Although good conditions for
adequate plaque removal are definitely necessary in any
type of dental replacement therapy, this principle does
not seem to have been adhered to in several of the suggested bonded splinting appliances. Compared with the
neat FSW retainer, the splinting appliances may appear
unnecessarily bulky and complicated. As discussed70,254,256
and illustrated (see Figures 14-58 and 14-59), the bonded
FSW retainer is preferrable.
Periodontal Conditions with Tooth Migration.
The bonded FSW retainer is well suited for stabilizing and
maintaining teeth into their new position after orthodontic treatment of adults with periodontal problems256,261 (see Figure 14-59). The main advantage over
removable retainers worn part time is that jiggling is
avoided. The FSW also may be used for periodontal
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Part II • Techniques and Treatment
A
B
C
D
Figure 14-64
Repair of broken retainer (fatigue fracture of wire between left central and lateral incisor), using labial
temporary wire for stabilization during rebonding. When the loose teeth have been pulled together with
steel ligatures (A and B) to close a small space, the temporary wire is bonded labially with adhesive after a
5-second etch. After setting, the steel ligatures can be removed to provide a nice working field (C), where the
repair wire can be bonded with no disturbed setting gingival to the main retainer wire (D).
splinting when teeth exhibit increased mobility or when
the mobility is of a magnitude that disturbs masticatory
function or patient comfort.96
Recently, extracoronal splinting using acid etching
and composite resins has been suggested, alone or
incorporating ligature wire, a perforated cast form, fiberthread or fiberglass,169 or grid material.186 Direct contact
splinting is not durable enough; composite over wire
ligation creates unnecessary bulk and compromises
esthetics; and the cast splints require expensive and
time-consuming techniques. Rosenberg186 reported that
the use of orthodontic grid-material splints is a completely reversible procedure. The splints are easy to construct and are inexpensive, and they require minimal
chairside time. However, all these advantages are also present in the bonded FSW retainer, which in addition has a
considerably neater and more hygienic appearance.261
To reduce failures in terms of wire fracture
(Figure 14-67) or loosening, it is important that the
patient try to avoid biting on a bonded maxillary retainer.
In some instances, a deep overbite will result only in
abrasive wear of the composite and wire without loosening. However, several studies indicate that direct biting on the retainer wire is the most common reason for
retainers coming loose.19 Following abrasion of the
adhesive, loosening occurs between composite and the
wire. Thus in cases of deep overbite, bonding the retainer
wire gingivally to the contact line (Figure 14-68) or, if
this is not possible, hiding the wire in a small groove in
the enamel is recommended.
Accidental loss of Maxillary Incisor(s). Most accidents in which maxillary central incisors are knocked
out of the mouth occur in the age period from 8 to
10 years.9
When orthodontic space closure is selected as the
treatment alternative (a discussion on indications is
presented elsewhere68,209,253), the canines and premolars frequently have not yet erupted, and a two-stage
orthodontic treatment is indicated. In the first stage the
lateral incisors are brought mesially to prevent bone
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Chapter 14 • Bonding in Orthodontics
641
A
B
C
D
Figure 14-65
Recommended version of removable plate to be used with a four-unit bonded lingual retainer. The rectangular
(0.019 × 0.026 inch) labial wire of this plate extends distal to the lateral incisors and has a soldered extension
wire to prevent flaring of the canines. A holding clasp of 0.8-mm round wire is distal to the second molars.
resorption and allow mesially directed eruption of the
canines. Then 1 to 3 years must pass until all permanent
teeth have erupted, at which time the second stage
of orthodontics can be performed. When removable
retainers are used in the waiting period between the two
stages, more often than not the patient perceives the
experience as a prolonged and tiring orthodontic treatment over too many years. The FSW retainer is excellent
in these situations. When the FSW retainer is bonded to
the lingual surfaces of the approximated lateral incisors,
the patient soon forgets about its existence, and consequently the patient is fresh and cooperative when the
final stage of orthodontics begins. Of course, a similar
approach can be chosen in other two-stage operations.
Mandibular Incisor Extractions. As discussed by
Joondeph (see Chapter 27), Tuverson,227 and others78,
sometimes one or two lower incisors are extracted as
part of orthodontic treatment. This may be true in some
adult patients and in patients with an open-bite
Class III tendency or a periodontal problem involving
excessive gingival recession on the most protruding
incisor. Whatever the reason for the extraction,
clinical experience indicates a high risk for space
reopening with conventional retainers, whether removable plates or fixed 3-3 retainers. By contrast, an FSW
retainer bonded to the three remaining incisors (or
extended farther distally; see Figure 14-58, F) safely
maintains the treatment results for as long as it is kept
in place.
Rotation of Maxillary Incisors. A well-known clinical problem is that severely rotated maxillary incisors
in different types of malocclusion have a great tendency
to relapse. This is particularly undesirable because the
upper anterior region is the most esthetically important
one for the patient.
Several techniques can be used to improve the stability,
including overrotation, fiberotomy, and extended
retention periods. Still another aid may be the placement of a bonded FSW retainer.
Whenever a removable plate is used in the maxilla
together with a bonded six-unit retainer, the version
shown in Figure 14-69 is recommended.
21-12 Retainer. The FSW retainer also can be bonded
to the four mandibular incisors as an alternative
to a bonded 3-3 retainer. The indications are primarily
when the operator is uncertain of the optimal
Graber-Ch-14 28/9/04 12:36 AM Page 642
B
A
D
C
F
E
G
H
Figure 14-66, cont’d
For legend see opposite page.
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Chapter 14 • Bonding in Orthodontics
643
Figure 14-66
Recommended routine retention for adolescent patients. Young girl with unilateral crossbite (A to C) after
orthodontic treatment involving four premolar extraction (D and E). F, After treatment. Retainers include an
upper four-unit flexible spiral wire retainer (G), a lower 3-3 bar (H), and a removable plate (see Figure 14-65
for design).
A
B
Figure 14-67
Fatigue fracture of a lingual retainer wire. A, A wire fracture has occurred between the right lateral and central
incisors. B, Significant abrasive wear of a bonded lingual retainer in the maxillary left canine area caused by
occlusal contact with the mandibular canine. The round wire has been worn flat. When a state of equilibrium is reached, such retainers still may be kept in place for several years because of the retentive potential
of the wire spirals.
A
B
Figure 14-68
A, If a deep overbite situation remains after treatment, the risk of loosening of a bonded lingual retainer is
obvious. B, To avoid occlusal interference, the retainer wire may be bonded gingival to the contact line.
intercanine distance or wants to canines to settle undisturbed for other reasons. However, because the longterm results are excellent for six-unit mandibular
retainers,70 little reason exists to use the four-unit
solution.128
Palatally Impacted Canines. Canines that have
erupted into the palate also may display great relapse
tendency in a lingual direction, particularly when
no interlocking lateral overbite is present. In such
instances an FSW retainer bonded to the lingual or
buccal of the teeth has proved to be an excellent retainer
(see Figure 14-58, G and H). The main advantage of the
FSW retainer is that it allows more undisturbed bone
and soft tissue healing over long periods than can be
obtained with removable retainers.
Conclusion and clinical recommendations
When it comes to finding simple, reliable, and neat
retainers and splints for a variety of clinical situations,
the bonded FSW retainer opens up a range of new
possibilities. The one limitation to its design and use in
difficult or unusual circumstances is the imagination
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Part II • Techniques and Treatment
A
B
C
D
Figure 14-69
A and C, Recommended version of removable plate to be used with a six-unit bonded lingual retainer. The
labial wire of this plate extends distal to the bonded retainer to avoid the risk of retainer wire fracture.
The acrylic of the plate can be ground away from the teeth involved in the bonded retainer, B and D.
and alertness of the operator. Clinical experience with the
FSW retainer over the past 20 years has been excellent
when meticulous technique was used62,223; otherwise,
results can be discouraging.
Because the failure rates increase significantly
when the canines (and first premolars) are included in
a maxillary FSW retainer (see Table 14-1), use of a fourunit design combined with a removable plate (see
Figures 14-65 and 14-66) rather than a six-unit bonded
retainer (Figure 14-70, see also Figure 14-69) is safer for
routine retention in children and adults.
The 3-3 bar and the 321-123 retainer show excellent
and similar success rates (see Table 14-1). The 3-3 bar is
a safe retainer, and this design may be recommended for
most children. For adults and adolescent patients with
pretreatment spacings and similar malocclusions, the
bonding of all six anterior teeth may be preferable.
Direct-Bonded Labial Retainers
Clinical experimentation with short labial retainers was
started in the late 1980s to try to improve the long-term
results in some specific retention situations. Typical
problems were the following:
1. 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
Common to these situations was that some support in
the premolar area for 1 to 2 years appears advantageous
to improve stability. The background for bonding retainer
wires labially was based on unsatisfactory results when
the orthodontist bonded wires to the lingual surface of
premolars.254,256,259 The alternative—bonding the wire
occlusally in the premolars—presents other problems.
In most instances antagonistic contact cannot be avoided
unless a groove is prepared, which is probably not acceptable in routine situations. It was decided therefore to
bond short retainer wires labially to examine success
rates and patient reactions.
Technical procedure
In principle the fabrication of labial retainers is similar to
the technique used for direct bonding of lingual retainers.
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B
A
D
C
F
E
Figure 14-70
Combination of six-unit bonded lingual retainer and simplified Crozat appliance for retention in adult
female patient with an anteriorly constricted maxillary dental arch and rotated and blocked out lateral incisors and canines (A to C). E, The Crozat is optimal for long-term retention of crossbites in adults. If the appliance is not worn for some time and slight transverse relapse occurs, its flexibility allows for recovery (similar
to a spring retainer), in contrast to what is possible with a conventional removable plate. Note improvement
of smile fullness (F) compared with the start (A).
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Part II • Techniques and Treatment
1. A straight piece of 0.0215-inch Penta-One wire
(gold-coated or stainless steel) is cut to the desired
length.
2. After etching, the retainer wire is tacked on the
teeth.
3. After the adhesive sets, a bulk of adhesive is
added.
4. Contour trimming of excess is done with tungsten
carbide burs (#7408 and #7006) and interdental
trimming is done with small round burs (#1 or #2).
Care is taken to avoid contact between composite
and gingival margin at the bonding sites, as well as
contact between the interdental papillae and the
retainer wire.
Long-term results
The first follow-up study of direct-bonded labial retainers
as reported by Axelsson and Zachrisson23 demonstrated
excellent results for short segments (two teeth) regarding
bond success rate and, surprisingly, for patient acceptance. A gold-coated labial wire (see Figure 14-51, B) is
understandably more acceptable than a steel wire, even
if some of the plating may wear off over time. The failure rates for retainers of two teeth were about 4% over an
average period of 2 years. The retainers were placed over
closed extraction sites in adults (Figures 14-71 to 14-73)
or for added retention of previously palatally impacted
canines (see Figure 14-58, H).
When longer retainers (three to four teeth) were placed
labially in the mandible, however, the bond failures
increased significantly.23
OTHER APPLICATIONS OF BONDING
Numerous other clinical possibilities of interest to
orthodontists exist in which the acid-etch technique
and bonding has proved useful:
• Space maintainers
• Semipermanent single-tooth replacements
• Trauma fixation
• Resin buildups for tooth size and shape problems
Bonded Space Maintainers
Several approaches to bonded space maintainers have
been described,15,170,201 with varying degrees of shortterm success reported. Long-term results on a group of
patients are not available for any design. Analogous to
the encouraging results with the bonded 3-3 retainers
are the findings of Årtun and Marstrander,15 who compared the durability of 64 space maintainers when a
round 0.032-inch wire with terminal loops or a twisted
stainless steel wire of 0.032-inch diameter without
loops was bonded with composite resin (Concise). A
utility wire design was used to reduce the influence of
occlusal forces. Although the failure rate after 6 months
was significantly higher for the first alternative, it was
in the 10% range for the second (an acceptable level).
The main reason for the difference was thought to
be the fact that the spiral wire allowed less bulk (and
thus less occlusal interference) and was easier to individualize. Simonsen201 reported bonding space maintainers on the lingual sides of teeth, apparently with
good success.
Figures 14-74 to 14-76 show more recent designs of
bonded space maintainers made from plain, round
0.032-inch stainless steel wire sandblasted terminally
for micromechanical retention or from gold-coated
0.030-inch wire.
More studies may be needed on specific designs of
bonded space maintainers on the labial or lingual
aspects before a variant for routine use can be accepted
universally.
B
A
Figure 14-71
A, Adult male patient with Class III malocclusion. B, Short labial retainer after extraction of mandibular first
premolars.
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Chapter 14 • Bonding in Orthodontics
A
647
B
C
D
Figure 14-72
Slight space reopening distal to a short labial retainer in an adult woman requiring upper first premolar
extraction. A and B, Gold-coated labial retainers. C, The reopening evidently reflects a tooth size discrepancy
that can be addressed when remaking the amalgam fillings. D, The labial wire is inconspicuous on smiling.
Bonded Single-Tooth Replacements
Because of the well-known problems with fixed bridgework and removable appliances of the spoon denture
type in young patients, acid etching and bonding offer
a range of esthetic techniques for the solution of the
problem with anterior teeth.184 The use of resin-bonded
bridgework (three-unit or cantilever40) has become
accepted as a semipermanent procedure. Failure rates
over a 10-year period may be in the 30% range,242 particularly if cases are selected to allow no or only limited
occlusal contact on the restoration. Higher failure rates
have been experienced with the presence of occlusal
contact, particularly in children.
A cheaper, simpler, and perhaps more durable alternative than the cast variants for anterior tooth replacement was proposed in 1984 by Årtun and Zachrisson.20
An acrylic prosthetic tooth was used into which were
inserted two flexible braided rectangular wires (0.016 ×
0.022 inch) and one round (0.0195-inch) spiral wire for
support.
The procedure aimed at the following properties:
1. Possibility for physiologic movement of the bridge
units within the periodontal tissues
2. Avoidance of direct occlusal contact on metal
3. Avoidance of metal shine through
4. Uncomplicated repair
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Part II • Techniques and Treatment
B
A
D
C
F
E
Figure 14-73
A to C, Young adult female patient with typical Class II, Division 2 malocclusion before treatment. The
maxillary first molar was extracted as part of treatment (C). The second molar and first premolar were held
together with a short gold-coated labial retainer. The maxillary third molar is erupting. D to F, Note the
improved maxillary canine occlusion and incisor torque.
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A
B
Figure 14-74
Recommended design for bonded space maintainers
using round 0.032-inch stainless steel wire sandblasted
in the terminal ends for micromechanical retentions
(A and B) or using six-stranded 0.032-inch spiral wire
with utility wire design.
A
B
C
D
Figure 14-75
A and B, Adult man in whom it was necessary to upright the mesially tipped mandibular left second and
third molars. C, Gold-coated 0.030-inch space maintainer. D, Before insertion of a single-tooth implant for
the absent first molar.
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Part II • Techniques and Treatment
A
B
C
D
E
F
Figure 14-76
A, Adult female patient with agenesis of two mandibular incisors and thin periodontal tissues. B to D, Goldcoated space maintainer. The mandibular left first and second premolars were moved one tooth width
mesially (B) to regenerate improved alveolar bone thickness to accommodate a single implant (E and F).
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651
B
A
Figure 14-77
Three-wire design for single tooth replacement of a missing right lateral incisor (A) and four-wire version of
the resin-bonded bridge, where the two braided wires run continuously through the pontic (B). Note the
attempts to achieve clean interdental conditions.
5. Access to the pulp cavity and root canal in cases
where endodontic treatment might be indicated
Clinical results with the three-wire design in a nonselected material without concern for the degree of overbite in 51 adolescents were promising but not entirely
satisfactory.20 Bond failure rates were 26% after 2 years
and 39% after 3 years. Most breakage occurred on central incisors in direct occlusal contact during protrusive
mandibular movements and were seen as wire fracture.
The failure rates were much lower when no antagonistic
contact with the pontic occurred during functional
movements. None of the lateral incisors had come loose
(Figure 14-77, A).
Later modifications have included an improved fourwire design, using two rectangular braided wires on either
side (Figure 14-77, B). In cases in which direct occlusal
contact could not be avoided, a small groove was prepared
to hide the incisal wire(s). In a nonselected sample of
36 bridges, the failure rate over 4 years with the fourwire design was about 20%.222
Despite these failure rates, this type of replacement has
several advantages for use in children and adolescents.
Of particular interest is the fact that similar types of
replacement can be used during orthodontic treatment.
Porcelain or acrylic teeth can be attached to neighbors to
avoid empty-looking spaces in adults when premolar or
incisor extractions are needed (see Figures 14-55 to 14-57)
and for absent maxillary lateral incisors while waiting
for a more optimal time for implant insertion.
Splinting of Traumatic Injuries
The goal of splinting traumatized teeth is to stabilize,
allow healing, and prevent further damage to the pulp
and periodontal structures. Several types of traumatic
splinting devices are used conventionally,9 but for vari-
ous reasons none of these splints is optimal.186 Thus
clinical experiments using different bonded wires are
interesting. Short-term studies have demonstrated
clinical success with bonded plastic wire and stainless
steel spiral wire.9 Such splints allow physiologic mobility of the splinted teeth, which has been found to be
preferable to rigid splinting (except possibly for root
fractures).
Composite Buildups and 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 shape and size problems. A range of situations
exist in which buildup techniques may provide esthetic
improvement of the orthodontic result.
For example, small or peg-shaped maxillary lateral
incisors (Figure 14-78) and canines brought into
contact with maxillary centrals when the laterals are
congenitally missing (Figure 14-79) may need such
esthetic improvement.65
Occasionally, autotransplanted first premolars in
the lateral incisor position also need the addition
of resin.
More demanding situations require porcelain laminate veneers or veneer crowns, including cases in which
premolars have been autotransplanted to the maxillary
anterior region.68,69,209 The esthetic result that may be
obtained with one or several porcelain veneers bonded to
prepared transplanted premolars is outstanding. The combined surgical-orthodontic-prosthetic interdisciplinary
effort is an excellent way to solve difficult treatment
problems associated with traumatic injuries of the teeth
in young patients.
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Part II • Techniques and Treatment
B
A
C
D
E
F
Figure 14-78
A and B, Young female patient with agenesis of maxillary right lateral incisor and peg-shaped left maxillary
lateral incisor. Clinical result of orthodontic space closure (C) was modified by recontouring the canine to
the lateral incisor shape by grinding and making a porcelain laminate veneer on the peg lateral (D and E).
E and F show final result.
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A
653
B
C
D
Figure 14-79
Composite buildup leading to esthetic improvement postorthodontically for a patient in whom the maxillary lateral incisors were missing. A, After space closure. Note the unfavorable appearance of both canines
and the traumatically injured right central incisor (arrows). B, Combination grinding of the canines and
composite buildup on the mesial aspects of the canines and the incisal edge of the central incisor. C and
D, Results of this quick procedure.
REFERENCES
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