BONDING IN

ORTHODONTICS
Presented By,

Dr. Girish G. Sarada

1ST year P.G.
Department Of Orthodontics & Dentofacial
Orthopedics

K.L.E. society`s Institute of dental sciences,

Bangalore
 EVOLUTION OF BONDING

For the orthodontic treatment to carry out, force is to be applied to the teeth, to
apply force we need some form of attachment over the teeth, so this can be done in two
ways
1. Banding
2. Bonding

BANDS - Bandless dentistry had been dream of orthodontists for many years. These
bands were introduced by W.E. Magill in 1871 & have been in existence for more than
100 years.
DISADVANTAGES OF BANDING

 Laborious, time-consuming
 Skilled work is required
 Difficulty in banding partially erupted teeth
 Decalcification /discoloration with loose or un-contoured bands
 Gingival irritation
 Unaesthetic
 Need of separators
 Closure of band spaces after completion of treatment

For the patient to whom esthetics being prime consideration even during treatment
,metallic look of fixed orthodontic appliance , has always been the bone of contention.
A survey of the developments in the field of orthodontics over last 50 years would
indicate that successful bonding of brackets to teeth, replacing conventional system of
cementing stainless steel bands with welded attachments is most significant achievement.
Since breakthrough of bandless dentistry in 1955, when buonocore described acid
technique to achieve to achieve micromechanical retention of resin to enamel, bonding
had come to stay.
 • HISTORY–

3 major developments that made bonding of attachments to teeth possible

1. BUONOCORE 1955 – improved retention of methyl methacrylate to enamel – 85%

phosphoric acid for 30 seconds
2. BOWEN 1962 – bis Glycidyl methacrylate – more stable and greater strength
3. NEWMAN 1965 – first to acid etch and bond orthodontic brackets with epoxy
resin

ACID ETCHING -Michael Buonocore in 1955

• The first bonding agent for restorative dentistry, Sevriton Cavity Seal introduced
in 1949 by Oskar Hagger, a Swiss chemist working in London, using
glycerophosphoric acid dimethacrylate, an unfilled acrylic resin.
• In 1955, Buonocore, borrowing the techniques of industrial bonding, enhanced
the adhesion with the phosphoric acid etch.

Micahel Buonocore was first to demonstrate that bonding of acrylic material was
substantially increased by conditioning enamel surface with 85% phosphoric acid for 30
seconds. Monomer of acrylic wet etched surface, flowed into each pits aided by capillary
action & generated retentive resin tags. Mainly used to seal pits & fissures.
This procedure has expanded the use of resin bonded restorative materials as it provides
a strong bond between resin & enamel, forming basis for many innovative dental
procedures like resin bonded metal retainers, porcelain laminates & bonded orthodontic
brackets.

Newmann in 1965-
Was first to apply these findings & bonded plastic brackets with an epoxy resin after
etching with 40% phosphoric acid for 60 seconds.

Mitchell in 1967 -
Described a successful although limited, clinical trial using black copper cement & gold
copper attachment.

Smith in 1968-
Introduced zinc polycarboxylate cement & bracket bonding with this cement.

Miura et al in 1971-
Described an acrylic resin ORTHOMITE using a modified trialkyl borane catalyst, that
proved to be particularly successful for bonding plastic brackets & for enhanced adhesion
in presence of moisture.

In 1975, Silverstone Three patterns of enamel etching.

1979 Maijer R. and Smith D.C.
introduced an alternative to acid etching.The crystal growth on the enamel
surface.

Bonding materials strong enough for clinical use did not become routinely available until
mid 1970‘s before that experimental bonding system based on epoxy & acrylic resin had
been proposed & evaluated clinically with success. The greatest difficulty with epoxy
resin was slow development of full strength, so it was not possible to place arch wires at
same visit the bonded attachments were placed. The early resin materials suffered from
their different thermal coefficient of expansion relative to enamel extended to weaken
bonds.
The adhesives used introduced in early 1970‘s were primarily those of powder-liquid
type of methyl methacrylate that did not incorporate a filler. During this period, all
adhesives introduced had to adhere to plastic brackets that were made up of
polycarbonate. As time passed however the weakness of plastic brackets became apparent
& metal brackets begin to be used.
From mid 1970‘s the paste type of adhesives emerged in which both base materials &
catalyst were dispensed as pastes to be to be mixed before being used for bonding. The
reason for change from powder & liquid type to paste was mainly due to change in type
of brackets used in bonding.
It was in 1977, first detailed post-treatment evaluation of direct bonding over a full
period orthodontic treatment was published.
In survey by Gorlick in 1979 in U.S. it was seen that 93% of orthodontist preferred
bonding for bracket placement

First commercially available orthodontic adhesives

1. OIS Adhesive system – OIS company in 1969.

=> Masuhara introduced -- called direct bonding system for enamel. It was one of the
first dental adhesive commercially introduced after Buonocore proposed the concept of
acid-etching enamel.

2. Bracket Bond – GAC in 1970

3. Fujio Miura and associates in 1971 –

• Introduced – ORTHOMITE
• MMA - Tri–N–Butyl Borane (catalyst)
• Increased adhesive strength
• Coupling agent – ‗silane‘ methacryloxypropyltrimethoxysilane
• Increased adhesive penetration
• Chemically bonded to adhesive
Affinity to enamel
Methyl Methacrylate – 1st used adhesive

Catalyst - BPO (Benzoyl peroxide)

Difficulty in adhesion
• Polymerization shrinkage
Pulpal irritation

Merits of MMA adhesives:

1. Plastic brackets
2. Good storage stability
3. Increased working time – brush-on / dip-in
4. Elimination of sealant - good penetration into enamel surface
5. Less damage during debonding
Demerits of MMA adhesives:
1. Fluctuating proportion of powder-liquid depending on operator
2. Poor mechanical interlocking to metal bracket bases

BOWEN 1962 :
Bisphenol Glycidyl Dimethacrylate (Bis-GMA)

• Greater strength
• Lower water absorption
• Less polymerization shrinkage
• 2-paste system
• Strongest adhesives for metal brackets

MERIT AND DEMERIT OF BIS-GMA

• Poor penetration due to increased viscosity – dilution reqd.
• Plastic brackets could not be used – primer for partially dissolving added
• Active life less than powder liquid system
 In 1974 – ORTHOMITE II
20% more HNPM –
hydroxy napthoxy propyl methacrylate
• Eliminated silane

ORTHOMITE SUPER BOND

 4 - META – methacryloxyethyl trimellitate anhydride

4 - META
• Bonds to Plastic & metal
• PRE-PRIMED brackets
• Base was primed with adhesive
• Bracket base covered with PMMA powder
• Base dipped in monomer and pressed onto etched surface.
• Bond strength less than manual application

Nanotechnology
has led to the development of a new composite resin characterised by containing
nanoparticles measuring approximately 25 nm and nanoaggregates of
approximately 75 nm, which are made up of zirconium/silica or nanosilica
particles.
 Advantages of bonding-
1. Esthetically superior.
2. Faster & simpler.
3. There is less discomfort for patient
4. Arch length not increased by band material
5. Allows more precise bracket placement
6. Improved gingival condition is possible & there is better access for cleaning.
7. Partially erupted or fractured teeth can be controlled.
8. Mesiodistal enamel reduction is possible during treatment.
9. Interproximal areas are accessible for composite buildup.
10. Caries under loose bands is eliminated. Interproximal caries can be detected &
treated.
11. No band spaces to close at end of treatment.
12. No large supply of bands needed.
13. Brackets may be recycled further reducing the cost.
14. Lingual brackets ‗Invisible Braces‘ may be used when esthetics important.
15. Improved appearance, deceased discomfort for patient & ease of application for
clinician.

Most important –
Improved appearance
Hygiene
Ease of application
Decreased discomfort for the patient
Disadvantages-
1. A bonded bracket has weaker attachment than a cemented band.
2. Few bracket adhesives are not strong.
3. Better access for cleaning does not necessarily guarantee better oral hygiene &
improved gingival condition, specially if excess adhesive extends beyond bracket base.
4. Protection against interproximal caries of well contoured cemented band is absent.
5. Bonding in not indicated on teeth where lingual auxillaries are required or where
headgear are attached.
6. Rebonding a loose bracket requires more preparation than rebanding a loose band.
7. Debonding is more consuming than debanding since removal of adhesive is more time
consuming.

TERMINOLOGY
Bonding -
 Process of joining 2 materials by means of an adhesive agent that solidifies during
bonding process.

• Types-
1. Physical bonding-
 Involves Vander wall / electrostatic interactions that are
relatively weak. It is the type of bonding seen when
surfaces smooth & chemically dissimilar.

2. Chemical bonding -
 Involves bonds between atoms are formed across
the interface from adhesive & adherand. Since materials are
dissimilar,the extent to which bonding is possible is
limited, overall contribution to bond strength low.

Mechanical bonding –
 Result of an interface that involves undercuts & other irregularities that produce
interlocking of the material.

Almost every case of dental adhesion is based primarily on mechanical bonding.

ADHESION-
 A molecular attraction between 2 contacting surfaces promoted by interfacial force of
attraction between molecules or atoms of two different species.
Can be chemical, mechanical or combination.

ADHESIVE-
Substance that promotes adhesion of one substance or material to another
Requirements-
1. Resist ambient temperature
2. Fluid enough to penetrate tooth surface but viscous enough to enable good bracket
positioning.
3. Set hard and tough
4. Tolerate/dissolve impurities
5. Not cure slowly, unduly shrink or allow discontinuities
6. Must wet tooth surface & flow into surface pores & valleys.
7.Contact angle – It is angle formed between interface of adhesive & adherent. It should
be zero for proper wetting of surface.
8. No change on solidification
9. Water absorbing tendency - minimal

SUBSTRATE / INTERFACE
1. It should be Clean & Firm
2. Allow air to escape as air if present acts as-
- Polymerisation inhibitor
- Decreases cohesion
Nature of Enamel –
Unique characters are -
1. Hardest
2. Only clinically visible mineralized tissue
3. No regenerative capacity
•
Morphologically – It has enamel prisms which results in Keyhole/ Fishlike appearance.
Enamel rod has 2 parts- Head & tail
Each prism contains hydroxyapatite crystals which are parallel to long axis in head region
& perpendicular in tail region
Crystal dissolves faster – Head region

Factors affecting Enamel solubility-

 Pre-eruptive-Hypoplasia/hypocaicification- infection of primary teeth

Excessive ingestion of fluoride
 Post-eruptive- Topical fluorides
Plaque/pellicle
• Above all factors decreases enamel solubility

Classification of Bonding Materials-

A) Based on basic bonding Materials-
 1- Acrylic based- Self curing acrylic
 2- Diacrylate based- Bis GMA/
Bowen‘s resin
 3- Glass ionomer

Basic difference between is acrylics are linear polymers where as diacrylates are cross
linked 3-D polymers.
•
B) Based on curing system-
 1. Self curing
 2. Light curing
 3. Dual curing
 4. Thermocured

C) Based on Fluoride system-

 1. Fluoride releasing
 2. Non-fluoride releasing
Adhesives acting in the presence of water

1. MOISTURE-RESISTANT
- can bond in presence of water
- saliva, gingival fluid – contaminants
- ex. Transbond MIP

2. MOISTURE-ACTIVE
- need water for bonding
- enamel surface intentionally made wet
- Cyanoacrylate – no liquid, only paste
- ex. Smartbond

Unfilled Acrylic Resins-

Widely used as adhesives in beginning but its use is limited due to its few properties.
Available in powder & liquid form.
Composition-
Powder - polymethyl methacrylate
Initiator- Benzoyl Peroxide approximately 0.3 to 0.5%.
Monomer- Methyl methacrylate
Cross linking agent - Ethylene dimethacrylate
Inhibitor- Methyl hydroquinone 0.006%

 Orthimite, Directon, Bondeze, Geine etc. are based on self curing acrylics

Properties-
 Unfilled
 Compressive strength- 70MPa
 Tensile strength –24MPa
 Elastic modulus-2.4GPa
 Thermal coefficient of expansion- 92.8ppm/ºC
 KHN- 15
 Water sorption- 1.7
 Curing shrinkage-2-3vol%

Disadvantages-
 Low hardness & strength
 Inferior resistance to abrasion
 High coefficient of thermal expansion
- microleakage
Composites-
Composite is a solid formed from two or more distinct phases that have been combined to
produce properties superior to or intermediate to those of individual components.

Dental Composite - It is a highly cross linked polymeric material reinforced by dispersion

of amorphous silica, glass, crystalline or organic resin filler particles &/ short fibers
bonded to matrix by a coupling agent.
•
There are 3 structural components-
Matrix – Plastic resin that forms continuous phase & binds filler particles.
Filler
Coupling agent
MATRIX – It is made up any of the following
 BisGMA
 Urethane dimethacrylate
 Triethylene Glycol Dimethacrylate (TEGMA)
High molecular weight that reduces polymerization shrinkage but increases viscosity.

Viscosity Controller-
 Methyl methacrylate (MMP)
 Ethylene glycol Dimethacrylate (EDMA)
 Triethylene Dimethacrylate (TEGDMA)
 Diethylene glycol Dimethacrylate (DEGMA)
•
Inhibitors-
 Butylated Hydroxytolune (BHT) - 0.01wt%
 Functions -
1. For adequate storage life
2. Ensures sufficient working time

Chemical Activation-
 Initiators - Benzoyl peroxide
 Accelerators - Tertiary aromatic amines
Eg- N,N-Dimethyl-p-toluidine
N,N dihydroxy ethyl-p-toludine
 Two pastes are mixed- amine reacts with BP forming free radicles & polymerization
is initiated.

Photochemical Activators
Initiator - UV light of 365nm
Activator - benzion ethyl ether
Initiator - Visible light of 420-450nm.
Activator - Diaketone such as camphoroquinone - 0.2wt%

Advantages of Visible light over UV light-

- Greater depth of cure
- Controlled working time

Optical Modifiers-
 Titanium oxide & aluminum oxide - 0.001-0.007wt%
 Visual shading & translucency

DISPERSED PHASE/ REINFORCING PHASE

 Quartz, fluorosilicates, glasses & glass ceramics.
 The glass or glass ceramic may be lithium aluminum, barium aluminum or strontium
aluminum silicates.
Purpose-
1. Reinforcement of matrix resin - increased hardness, strength, decreased wear.
2. Reduction of polymerization shrinkage.
3. Reduction in thermal expansion & contraction.
4. Improved workability by increasing viscosity.
5. Reduction in water sorption, softening & staining.
6. Increased radiopacity & diagnostic sensitivity through incorporation of strontium &
barium glass & other heavy metals.
•
 Concise, Solo-Tach, Nuva-Tach -3 to 20 µm impart abrasion resistance properties.

 Endur, Dynabond - 0.2 to 0.3µm smoother surface that retains less plaque & is prone
to abrasion.

COUPLING AGENT
 Filler particles bonded to resin matrix
 Titanates & Zirconates
 Organosilanes like γ-emethacryloxypropyl-trimethoxy-silane
 Improves physical & mechanical properties
 Inhibits leaching by preventing water from penetrating along resin-filler interface
• Bonding agents- Physical properties
Classification – based on particle size
1. Traditional/macrofilled

 Filler size – 1-50µm

 Average- 8-12µm
 Filler loading 70-80wt%
 Compressive strength- 250-300MPa
 Tensile strength – 50-65MPa
 Elastic modulus- 8-15GPa
 Thermal coefficient of expansion- 25-35ppm/ºC
 KHN- 55
•
2. Hybrid (small particle) –

 Filler size – 0.5-3µm

 Filler loading – 80-90wt%
 Compressive strength- 350-400MPa
 Tensile strength – 75-90MPa
 Elastic modulus-15-20GPa
 Thermal coefficient of expansion- 19-26ppm/ºC
 KHN- 50-60
 Curing shrinkage-2-3vol%
•
3. Hybrid (all purpose)

 Filler size – 0.4-1µm

 Filler loading – 75-80wt%
 Compressive strength- 300-350MPa
 Tensile strength – 40-50MPa
 Elastic modulus-11-15GPa
 Thermal coefficient of expansion- 30-40ppm/ºC
 KHN- 50-60
 Curing shrinkage-2-3vol%
•
4. Microfilled-

 Filler size – 0.04-4µm

 Filler loading – 35-67wt%
 Compressive strength- 250-350MPa
 Tensile strength – 30-50MPa
 Elastic modulus-3-6GPa
 Thermal coefficient of expansion- 50-60ppm/ºC
 KHN- 25-35
 Curing shrinkage-2-3vol%
 •

Flowable composites –

Modification of small particle filled & hybrid composites. They have reduced filler level
so as to provide a consistency that enables the material to flow readily, spread uniformly,
intimately adapt to tooth surface.
Properties-
 Filler size – 0.6-1µm
 Filler loading – 40-60wt%
 Elastic modulus-4-8GPa
 Curing shrinkage-3-5vol%
Packable composites-
 Filler size –fibrous
 Filler loading – 65-81wt%
 Elastic modulus-3-13GPa
 Curing shrinkage-2-3vol%

•
 Chemistry
Basic
• Dental resins solidify when they polymerize.
• Polymerization occurs through a series of chemical reactions by which the
macromolecule, or the polymer, is formed from large number of molecules known
as monomers.

Monomers may be joined by either:

1. Addition polymerization
2. Step- growth or condensation polymerization

Addition polymerization
• Most dental resins are polymerized by this mechanism in which monomers add
sequentially to the end of a growing chain
• Compared with condensation polymerization, add polymerization can produce
giant molecules of almost unlimited size.
• Also there is no change in composition i.e. the structure of monomer is repeated
many times in polymer

• Requirement :-
An unsaturated group (having double bond)
e.g. Ethylene C2H4
A free radical I*

When the free radical & its unpaired electron approach a monomer with its high
electron density double bond, an electron is extracted, & it pairs with the electron
to form a bond between the radical & the monomer molecule , leaving the other
electron of the double bond unpaired
 - Thus the original free radical bonds to one side of the monomer molecule & forms
a new free radical site at the other end.
- The reaction is now initiated.

STAGES IN ADDITION POLYMERIZATION

1. Induction
2. Propagation
3. Chain transfer
4. Termination

Induction
Activation of monomer molecules

Free Radicals

In light activated system Camphoroquinone & Dimethyleaminoethylemethacrylate will

generate free radicals.
Visible light => 470 nm wavelength

Propogation
- The resulting free radical- monomer complex then acts as a new free radical
center when it approaches another monomer to form a dimer, which also becomes
a free radical.
- This in turn, can add successively to a large no. of molecules so that the
polymerization process continues through the propagation of the reactive center.

TERMINATION

1. Direct coupling
 Ii Mm*+ IiMn* => Ii Mm MnIi

It become deactivated by an exchange of energy.

2. Exchange of hydrogen atom

The hydrogen atom is transferred from one growing chain to another.

The double bond is created in this transfer

STEP GROWTH POLYMERIZATION

• The polymerization is accompanied by repeated elimination of small molecules

(byproducts)
• Functional groups are repeated in the polymer chain.
Slow process, reaction follows step wise pattern i.e. monomer – dimer – trimer- so for

Glass ionomer cement

Glass Ionomer is generic name of group of materials based on reaction of silicate glass
powder & polyacrylic acid. This acquires its name from its formulation of glass powder
& an ionomer that contains carboxylic acids
GIC were introduced in 1972 primarily as luting agent & direct restorative properties
with unique properties for bonding chemically to enamel dentin being able to release
fluoride ions for caries protection.
It is used routinely for cementing bands because they are stronger than zinc phosphate &
zinc polycarboxylate cement with less demineralization at the end of treatment.
•
Composition-
Powder-
 It is an acid soluble calcium fluroaluminosilicate
 Silica, aluminum oxide , aluminum fluoride, calcium fluoride, sodium fluoride &
aluminum phosphate
 Lanthanum, strontium, barium, or zinc oxide – provides radiopacity.
 Raw materials are fused at 1100 -1500ºC to a uniform glass.

Liquid-
 Polyacrylic acid- 40-50%
 Itaconic / Maleic acid - Increase reactivity & reduce viscosity
 Tartaric acid - improves handling characterstics & increases working time

 Rexn- Acid base

Glass + Polyelectrolyte = Polysalt hydrogel
+ silica gel
Porperties-
 ST – 7 min
 Film thickness – 24
 Compressive strength- 86
 Tensile strength –6.2MPa
 Elastic modulus -7.3GPa
 Solubility in water- 1.25wt%
Advantages -
 1. Ease of debonding
 2. Controllable working time
 3. No iatrogenic enamel damage
 4. Fluoride release
 5. Resistance to acid erosion
 6. Adhesion to enamel & metallic bases

Limitations-
 Short working time
 Initial sensitivity to moisture & dehydration
 Slow development of strength & elastic modulus
 Low fracture toughness
 Low abrasion resistance

Need for GIC for bonding

• The use of composites for bracket attachment has a number of disadvantages.
• Enamel may be lost during prophylaxis, acid etching and at the time of clean up
of residual resin at debond, as well as during rebonding procedures (Thompson
and Way, 1981; Silverston, 1974; Pus and Way, 1980).
• The concentration of fluoride is greatest at the enamel surface (Thompson and
Way, 1981) and the loss of this surface material is therefore of concern.

Larry White in 1986 described method of bonding orthodontic brackets with GIC. The
earlier chemically cured GIC typically took 24 hours to reach optimal bond strength
therefore arch wires had to be deterred or else very light force generating arch wires
could be only placed.

Silverman et al introduced in 1995 a light curing GIC for orthodontic bonding Fuji
ortho LC. They have recommended a no etch technique for bonding & claims it to bond
satisfactory in presence of moisture. They reported failure rate of approx 3% comparable
to that of bonding resins which indicate its clinical satisfactory.

Advantages
Faster setting
Show higher initial & sustained shear bond strength
Types
 1. Modified composite - Compomer or polyacid modified composite resin
 2. True resin modified / Hybrid ionomer
Compomer-
Essentially resin matrix composite. It consists of silicate glass particles, sodium fluoride
& polyacid modified monomer without any water. Because of absence of water cement
mixture is not self adhesive.
- Filler replaced by ion leachable aluminosilicate
- No acid base reaction during setting
- Light activated free radicals polymerization of methacrylate groups.

True Resin modified-

Replacing part of polyacrylic acid with hydrophilic monomer.
It incorporates acid base reaction.
Composition-
Powder-
Ion- leachable fluoroaluminosilicate glass particles
Initiators for light & / chemical curing.
Liquid-
Water
Polyacrylic acid or Polyacrylic acid modified with methacrylate & hydroxyethyl
methacrylate (HEMA) monomers.
Advantages
-Better early strength compared to conventional GIC.
-Reduce moisture sensitivity
-Improvement of translucency
-Higher bond strength compared to conventional GIC.
But polymerization shrinkage on setting can increase microleakage.
 Compressive strength- 105
 Tensile strength –20
 KHN-40
 Increased early strength
 Less moisture sensitivity

Literature
Bond strength and durability of glass ionomer cements used as bonding agents - AJO
July 1989

-Klockowski, Davis, Joynt, Wieczkowski, and MacDo

• Compared GICs (Ketac-fil, Ketac-cem and Chelon) with Rely-A-Bond (no-mix

autopolymerising) which served as a standard in a clinical study.
Results:
• Bond strength of GICs was significantly less when compared to Rely-A-bond.
• Less reduction of bond strength of GICs on recycling – lesser than Rely-A-bond
on recycling
• Failures involved cohesion within cement or adhesion involving the enamel -
easily scraped off from the enamel surface without causing much damage.
 • Cook -1990 compared the in vivo bond strength of a glass ionomer cement,
Ketac (ESPE Premier Denbol Products, Norristown, Pa.), with a composite resin
bonding agent – 12% failure rate

• Fajen et al- 1990 evaluated the bond strength of three glass ionomer cements
against a composite resin in vitro

• Fricker - 1994, worked with Fuji II LC glass ionomer cement (GC Corp., Kyoto,
Japan)

• Same rate of success bonding brackets to enamel surfaces as he did with

composite cements.
• Dentine conditioner was utilized for ten seconds

A new light-cured glass ionomer cement that bonds brackets to teeth without etching in
the presence of saliva - AJO-DO SEP 1995
- Silverman, Cohen
• Used a new Resin modified GIC
• Fuji Ortho LC
• Light-cured, resin-reinforced glass ionomer cement
3 mechanisms of setting

Advantages:
• Saves significant amount of chair time.
• Eliminates working in a dry field.
• Eliminates etching and priming enamel surfaces.
• Fluoride release protects teeth against decalcification.
• Repairs are quick and easy.
• Increased patient and operator comfort.

EJO 2004 April according to S.B. Oliveria et al

• There is no significant bond strength difference occurred when compared to
composite resin when used with light and medium arched wires. So RMGIC is a
viable alternative when used with light & medium arch wires.

Aug 2004 AJO-DO by Andrew Summers et al

• bond strength, highest is achieved by conventional chemically cured composite
followed by RMGIC & least by GIC
 BONDING PROCEDURE

DIRECT BONDING-

1. CLEANING-

Thorough cleaning of teeth with pumice is essential to remove plaque & the organic
pellicle that normally covers all teeth. Cleaning is done using rotary instruments either a
rubber cup or polishing brush. A bristle brush cleans effectively after cleaning rinse.
Reisner et al found more consistent results when Buccal tooth surfaces were abraded
lightly with a tungsten carbide bur(#1172) at slow speed (25,000rpm) than pumiced for
10 secs before acid etching.

2. ENAMEL CONDITIONING-

a. Moisture Control-
After the rinse, salivary control & maintenance of a completely dry working field is
absolutely essential.
Some measures are-
1. Lip Expander- For simultaneous premolar to premolar bonding in both arches.
2. Dri-Angles to restrict flow of saliva from parotid duct.
3. Combined saliva ejector- tongue holder to remove moisture from mouth.
4. While bonding mandibular second molar use of double hygoformic saliva ejector & T
tube is indicated.
5. Antisialogogues are generally not recommended. Different preparations used are
Methantheline bromide (Banthine), Propanthaline bromide(Probanthine ), atropine
sulfate.
Excellent & rapid saliva flow restriction is obtained by Propanthaline bromide injections.
Whenever indicated Banthine tablets 50mg per 100 lb(45kg) in sugar free drink 15 min
indicated.
6. Cheek retractors
7. Gadgets that combine several of these.
8.Cotton or gauze rolls.
Various means for moisture control-
•
• Dri angle Salivary duct obstructor
 Saliva ejector, tongue High speed evacuator
holder, bite block

ANTISIALOGOGUES –
They help to decrease salivary release from glands & ducts unlike other devices that
control released saliva.

• Atropine sulphate - In JCO-1981 Sidney brant Showed this is a safe drug with
few complication & can be used as an sublingual injection
(Dose-0.4 mg)
• Banthine tablets –In JCO 1981 Richard .N. Carter reported that 50 mg per 100 lb
in a sugar free drink 15 min before bonding is adequate.

b.Enamel Pretreatment-
• Acid etching
• Other alternatives to acid etching
1. Crystal growth
2. Sand blasting/air abrasion
3. Laser etching

Acid Etching-
Process of roughning a solid surface by exposing it to an acid & thoroughly rinsing
the residue to promote micromechanical bonding of an adhesive to the surface.
The conditioning solution or gel usually 30% to 50% phosphoric acid typically
37% is preferred
Calcium monophosphate & ca. sulfate byproducts – removed by water rinse

Concentration greater than 50% - Deposition of adherent layer of monocalcium

phosphate monohydrate on etched surface which inhibits further dissolution

Concentration less than 27% creates dicalcium phosphate monohydrate precipitate that
cannot be easily removed & may interfere with adhesion

 Apply over enamel surface - foam pellet, brush for approximately 15-30 seconds.
 To avoid damaging delicate enamel rods care should be taken not to rub liquid onto
tooth.
 Etchant is washed with abundant water spray.
 High evacuator - increased efficiency in collecting etchant water rinse & reduce
moisture contamination.
 Thoroughly wash with moisture & oil free surface to obtain dull, frosty appearance.
 Etched enamel - higher total surface energy which ensures that a resin will readily
wet surface & penetrate into resulting microporosity.
 Once resin penetrates into porosity it can be polymerized to form resin tags that
produce mechanical bond to enamel.
 If contamination occurs re-etch again.
 Cervical enamel due to its different morphology usually looks different from central
& incisal portion of tooth.
 Etching entire facial surface is harmless but logically etch an area only slightly larger
than pad
 Acid in gel or solution
 Gel provides better control.
 Gels are prepared by adding colloidal silica or polymer beads to acid.
 Fluoridated phosphoric acid solutions and gel provides same morphological etching
pattern. & have adequate strength.

 Mostly used gel -Ultra Etch 37% phosphoric acid blue gel
 Advantages-
1. Adequate contrast
2. Smooth consistency
3. Ideal viscosity
4. Provides even nicely demarcated white frosted appearance

Alternative acids for etching

traditionally :- 30 – 40 % Phosphoric acid

- 10 % Phosphoric acid
- 10 % Maleic acid
- 2.5 % Nitric acid
Type and concentration of Acid
A. Liquid
B. Gel

Bond Strength
 37% phosphoric acid – highest bond strength – 28 MPa
 10% maleic acid – 18 MPa

Wang and colleagues ( Angle 1994) evaluated several phosphoric acid concentrations
from 2% to 80% and found that best bond strength was achieved with 30%-40%
concentrations
 Rationale of etching
Gwinnett, Matsui & Buonocore

Primary mechanism of attachment of resin

Resin tags to etched surface

MICROMECHANICAL BOND

 Acid etch removes 10 microns of enamel

 Creates porous surface
 Increases wettability

Timing-
 Young permanent teeth -15-30 secs.
 Deciduous teeth- Sandblast with 50 µm Aluminum oxide for 30 secs to remove
outermost aprismatic enamel & etch for 30 secs with 35% phosphoric acid gel.
 Adult- 60 secs
 Premolars,canine, anteriors- 15 secs
 First molar- 30 secs
 10- 30 secs – No effect on bond strength
 Less than 5 secs- Decreased bond strength
 Scanning electron microscopy- 30 secs produces optimal etching than 15 secs
•
 Normal thickness of enamel is 1000- 2000µm
 Etching removes 3-10µm of surface enamel
 Histological alteration of 25 µm
 Deeper – 100 µm

Care taken while etching acquired & developmental demineralization.

- Short etching time
- Apply sealer / primer
- Use bonding agents with extra care not to have any adhesive deficiency

Study of Etched Enamel Under Scanning Electron Microscope-

Bonding should have sufficient strength to resists application of orthodontic force to
move teeth, at the same time should facilitate easy & a traumatic debonding attachments
& minimum clean up procedure of enamel subsequent to removal of appliances.
Various studies have been carried out to define optimal concentration of acid used for
etching with phosphoric acid. These investigations include study of etched enamel
surface pattern under scanning electron microscope highlighting the loss of enamel , test
of shear bond strength of a bonded attachment to a correlated etchant concentration &
duration of etching & trauma to enamel & amount of adhesive on surface of enamel
subsequent to debonding.
Diedrich typed action of etchant on enamel in 3 stages-
The above mentioned etched patterns of etched enamel surface given by Silverstone et al.

Patterns of etching
Gwinnett & Silverstone

Type I- Core etching

A. Honeycomb pattern – ( Initially periphery of prism head is delineated
by micro- clefts (0.1-0.2Mm) continued action of acid leads to loss of
substance predominantly in area of prism cores with simultaneous
conservation of marginal areas
Least amount of enamel is lost in this etch pattern.

Type II – Periphery etching

Peripheral etching pattern is an advanced stage in which fragile prism
peripheries break off.. Max enamel loss takes place in this stage
Type III – Mixed pattern
As action of acid proceeds there is dissolution of crest like marginal
ridges, while marginal clefts continue to widen. This transitional zone of
central & peripheral etching pattern in which existing marginal ridges are
elevated to 3µm

Galil & Wright desribed Type IV & V

Type IV- Etch pattern commonly seen in cervical areas. It shows irregular pattern &
displays no rod or prism pattern.

Type V – Shows no prism outline. Enamel surface is extremely flat & smooth & they
lack micro-irregularities for resin penetration.

Iatrogenic effects of acid etching-

 Fracture & cracking of enamel on bonding
 Increased surface porosity- staining
 Loss of acquired fluoride in outer 10 µm of enamel surface
 Resin tags retained- discoloration
 Rougher surface if overetched

Bond strength with various etching times

WEI NAN WANG ET AL AJO 1991
• Compared the tensile bond strength at various etching times 15, 30, 60, 90, 120
secs
• 37 % phosphoric acid
• TBS was not statistically different for 15,30,60,90
• TBS decreased – 120 secs
• Debonding – fewer enamel fragments with shorter etching times

ALASTAIR GARDNER , ROSS HOBSON AJO 2001

• Compared quality and quantity of enamel etch produced by 37 % phosphoric acid
and 2.5% nitric acid for 15 , 30 ,& 60 secs
Concluded
• 37 % phosphoric acid - better etch for all 3 applications
• 15 < 30 & 60
• 30 = 60
• Supported use of 37% - 30 secs to get optimum bond strength

The continuous brush acid technique

BAHARAV , LANGSAM J PROSTH DENT 1987
• Aim was to determine whether mechanical agitation of etchant would enhance
decalcification of enamel
 • Non carious pre molars
1. Mesial half – 35% P04 acid[30 secs] left undisturbed
2. Distal half – 35% po4 acid [30 secs] continuously painted

• Results
• Continuous brushing of etchant - more efficient dissolution of enamel
• Reduction of size of remaining crystals
• Hence increasing the potential space between them for retention

Alternatives to acid etching

• CRYSTAL GROWTH
• SAND BLASTING/ AIR ABRASION
• LASER ETCHING

Crystal growth
SMITH
Polyacrylic acid – chemical bonding
Purified polyacrylic acid- slight etching
Polyacrylic acid + sulfate ion – crystalline deposit
CALCIUM SULPHATE DIHYDRATE
Depends on concentration of sulfate ions

MAIJER AND SMITH AJO 1982

Crystalline interface produced tensile bond strength equivalent to conventional
acid etched surface
Debonding => fracture at crystal - resin interface
n
Other sol – sulphuric acid anion[more reliable and uniform growth

Procedure
• One drop of viscous liquid placed on tooth surface
• Left undisturbed for 30 secs
• Brush / swab should not be agitated as in etching as it may affect crystal/enamel
interface
• Rinsed for 20 secs

• Forceful water spray to be avoided as it will break crystals

• Look out for a dull whitish deposit
 • Bracket bonded in usual way
• These crystals grow in so called spherulitic habit

MECHANISM OF RETENTION
• Calcium sulfate crystals must enucleate from bound calcium
• To achieve this some etching is required
• Enamel solubility ~ crystal enucleation
• Mechanical attachment is created around the crystalline interface and
superficially etched enamel

Phosphoric acid etched Crystal growth on

enamel surface enamel surface

ARTUN AND BERGLAND

• Sulphuric acid - crystals not as long and needle like as with polyacrylic acid but
were rounder and flatter
Hence debonding was easier

Advantages of crystal growth

• Debonding easier and quicker
• Little damage to enamel
• Minimal effect on outer fluoride containing enamel
• No resin tags left behind
• Possibility of incorporating fluoride in crystal interface – anticariogenic action

Crystal growth
JOHN ARTUN , S. BERGLAND AJO 1984
• Soln A – dil. sulphuric acid + sodium
sulphate
• Soln B – 10% po4 acid +dil. sulphuric acid
• Failure rates recorded – 6 months
• A > B > ACID ETCH

Sand blasting / air abrasion

Also referred as Micro etching in which particles of aluminum oxide are propelled
against suefrace of enamel by high air pressure causing abrasion of surface.
 Resultant bond strength is 50% of those to conventional acid etching.
Its a older technique of enamel pretreatment introduced as early as 1940 by Dr. Robert
Black.
It uses abrading with 50 µm or 90 µm particles of aluminium oxide for 3 sec at 10 mm
distance.
Used for cavity preparation
Preparation of enamel /dentin

• Factors affecting bond strength

1. Particle size
2. Air pressure
3. Exposure time
4. Microstructure of enamel surface

37% H3PO4 acid 90 um AlO2 air abrasion

WENDALA VAN WAVERAN, ALBERT FEILZER AJO 2000

 Compared bond strength and enamel loss between sand blasting and conventional
acid etching at varying exposure times and air pressure
 Bond strength
 Sand blasting < acid etching
 Enamel loss
 Sand blasting < acid etching

AJO-DO 1997 Marc .E. Olsen et al

 reported that air abrasion significantly decreases bond strength & on debonding
leaves no adhesive on enamel surface.
• So it is not recommended.
 Laser etching
LASER

• Light Amplification By Stimulated Emission Of Radiation

3 elements
• Lasing medium [ solid/liquid/gas]
• Energy source[xenon flash lamp/electrical discharge]
• Optical resonator
1. Coherence
2. Collimation
3. Monochromaticity

When laser strikes an object it may be

• Reflected
• Transmitted
• Scattered
• Absorbed
• Combination of above

This new concept was proposed in 1993, by J.A.Von Fraunhofer.

• At 3 watts for 12 sec laser etching = acceptable bond strength though
significantly less than conventional acid etching.
• He used Nd/ YAG as laser source.

• Serder Usumuz et al in AJO-DO 2002 used ErCr ; YSGG as the hydrokinetic

laser system for acid etching & came to the same conclusion.

Classification
• Mode of excitation ( Continuous or Pulsed)
• Wavelength
1. UV range(Krypton Flouride, Argon Flouride)
2. Visible Light ( Helium , Neon )
3. Infra Red range ( carbon dioxide, Nd:Yag)

 Application of laser causes localized melting & ablation.

 Removal of enamel primarily occurs by micro-expulsion of entrapped water in the
enamel.
 There may be melting of hydroxyapatite crystals

Laser etching with Nd : Yag M.A WILSON ET AL

• Studied the surface effects of dentin following
laser etching with Nd:Yag and evaluated the
shear bond strength of composite between
treated and untreated laser etched dentin
• Surface roughness
 laser etched > unlased dentin
• Bond strength
Laser treated >unlased dentin

LYDON COOPER ET AL
• Shear bond strength of composite to laser pre treated dentin increased by 300 %
localized melting + recrystallization
Fungiform projections
• The composite adapted to undercuts & space between the dentin projections

SEM picture of enamel after 37% SEM picture of enamel

after phosphoric acid etching laser etching of 2 W output

Pulsed krypton fluoride excimer laser

Dr Francis M
 Compared surface morphology, bond strength, and ARI between acid etching and
3 different energy densities of pulsed krypton fluoride laser
 440, 460, 480 MJ/cm2
Concluded :
 TBS 460> 480 >A E >440
 SBS 480 > A E > 460 > 440
 SEM regular etch pattern similar to acid etch seen with 460 & 480 MJ/cm2

Törün Özer et al (AJODO Aug 2008)

• compared shear bond strengths, enamel surface characteristics, and adhesive
remnant index (ARI) scores of bonding with laser irradiation, phosphoric-acid
etching, and SEP systems.
Results
• Irradiation with the 0.75-W laser produced lower shear bond strengths than the
other methods
• No difference for enamel characteristics
• ARI scores no diff. except for 0.75 W laser group.
• 0.75 W group => not suitable
 LASER ETCHING UNIT

3. SEALING
After teeth are completely dried & appear frosty white, a thin layer of sealant is
applied over entire etched enamel surface with a small foam pellet or brush with a single
gingivoincisal stroke.
Sealer is a hydrophilic , low viscosity resin that promotes bonding to substrate such as
dentin Coated in thin layer. It is thinned with gentle air burst for 1-2 secs.

Research is going on to determine the exact function of intermediate resin in acid etch
procedure.
- Some investigations conclude that intermediate resin is necessary to achieve proper
bond strength.
- Sealing permits a relaxation of moisture control.
- Sealants permits easier bracket removal.
- They protect against enamel tear outs at Debonding

Light polymerizing resins-

 Permits relaxation of moisture control
 Provides cover over adhesive voids - indirect bonding
 Ceen & Gwinnet- Light polymerized sealants protects enamel adjacent to brackets
from dissolution & surface lesions.
 Permit easier bracket removal

Chemical curing primers-

 Poor polymerization
 Drift
 Low resistance to abrasion
Self Etching Primers (SEP‘s)
Main feature of single step Etch/primer bonding system is that no separate acid
etching of enamel & subsequent rinsing with water & air spray required. Liquid itself has
component that conditions enamel.
Active ingredient of self etching primer is a methacrylated phosphoric acid ester that
dissolves calcium from hydroxyapatite. Removed calcium forms complex & is
incorporated into network when primer polymerizes.
Etching & monomer penetration to exposed enamel rods are simultaneous.
3 mechanisms for self etching process-
1. Acid groups attach to monomer are neutralized by forming a complex with calcium
from hydroxyapatite.
2. Solvent is removed from primer during airburst step, viscosity rises showing transport
of acid groups to enamel interface.
3. Primer is cured & monomer are polymerized, transport of acid groups to interface is
stopped.
Clinical procedure-
1. Dry tooth surface.
2. Apply Transbond Plus
1st compartment- Methacrylated phosphoric acid ester
Photosensitizers
Stablizers
nd
2 compartment- Water soluble fluoride
3rd compartment- Applicator microbrush
Sqeeze & fold first compartment over second activates
system. The mixed component then ejected into 3rd to wet applicator tip. Rub thoroughly
atleast 3 secs & always wet surface with new solution to ensure monomer penetration
3. Bond bracket with Transbond XT & cure with light
Scanning electron microscopy shows following etching pattern -

Acid etching SEP treated

 Study by Helen Grubisa et al – shear bond strength with SEP‘s is less than
conventional acid etching. AJO 2004

Moisture Insensitive Primers-

Reduce bond failure under moisture contamination hydrophilic primers that bond in wet
condition. They contain hydrophilic methacrylated monomer
Transbond MIP, 3M/Unitek
Indications-
 Second molar bonding
When there is risk of blood contamination on half erupted teeth or on impacted teeth
Hydrophilic resins polymerize in presence of slight amount of water but will not
routinely compensate for saliva contamination.

Literature
1. Effect of self etch primer on shear bond strength of orthodontic brackets
Samir Bishara & Leigh Von Wald
AJO 2001
• Their study concluded that use of self etch primer resulted in low but clinically
acceptable shear bond strength.
• Comparison of ARI scores – More residual adhesive remained with self etch
primer.

2. Bonding of stainless steel brackets to enamel with new self etch primer
Ryan Arnold et al AJO sep 2002
• Bond strength of stainless steel brackets using Transbond self etch primer
Four groups
A- Conventional etchant with separate primer
Group B
a- Self etch –15 sec Before
b- Self etch - 2 min bonding
c-Self etch - 10 min
Conclusion –
• No significant difference in bond strength between the two groups.
• 10 min delay in bonding after application of self etch primer might not be
deleterious for adhesion

3. Asgari et al (JCO 2002) did a clinical study of Transbond SEP in 20 patients

=> the bond failure rate using Transbond Plus Self Etching Primer was significantly less
than the bond failure rate in those quadrants where a 37% phosphoric acid etchant was
used.
 • 4. BONDING
STEPS

Four steps
1. Transfer
2. Positioning
3. Fitting
4. Removal of excess

Instruments-

Transfer-
Bracket is gripped with pair of cotton pliers or reverse action
tweezer & mixed adhesive is applied to back of bonding
base.

Earlier brackets were welded to band.

Disadvantages of this technique includes-
 Extensive chair time
 Frequent screening for caries
 Periodontal – leaching of cements

•
Positioning-
Placement scaler can be used to place bracket on tooth surface.
For Vertical positioning-Height gauges/boon‘s gauge is used
where as for horizontal positioning mouth mirror can be used.
Bracket pushed against the surface firmly. Tight fit is very
important as it results in
- Good bond strength
- Little material for debonding
- Optimal adhesive penetration at bracket base.
- Reduced slide

Undisturbed setting-optimal bond strength

•
• Removal of excess-
- Prevent or minimize gingival irritation & plaque build up
- Reduces periodontal damage
- Prevents Decalcification
- Improve aesthetic appearance
•
Removing excess adhesive why?
• To minimize gingival irritation by preventing plaque accumulation around the
periphery of bracket base.
• To reduce periodontal damage
• To prevent possibility of decalcifications.
• It avoids bridging when tooth are crowded
• Improves esthetics.
• Facilitate debonding.

Small & large TC burs are used to remove excess set adhesive

Curing - Once excess is removed it is cured.

Curing lights
• Tungsten quartz halogen light
• Argon laser
• Xenon plasma arc light
• light emitting diode curing units[LED]
• Pulsed xenon plasma arc light

Tungsten quartz halogen curing light

when electric energy is passed

Halogen bulb

Tungsten filament is heated HEAT

LIGHT

Selective filters – blue light [ 400-500 microns]

• 40 seconds per bracket

• 15 minutes – both arches
Disadvantages
• Time consuming
• Light output < 1% of consumed electricity
• Lifetime – 100hrs
• High heat - degrades components of bulb

Argon laser
• Introduced in the late 80‘s & early 90‘s
• Promised to reduce the curing time dramatically
• 480 microns wavelength
• Curing time
 • 3 secs – per bracket
• 1 min – both arches

• KELSEY ,POWELL
To equal bond strength of 40 sec exposure by conventional curing light argon laser must
cure for 10 seconds
Disadvantages
• Laser unit large
• expensive

Xenon plasma arch light

• Introduced in the late 1990‘s
• Short exposure time at lower cost
• Curing time
3 – 5 secs per bracket

Comparison of efficiency of xenon plasma

light and conventional curing light Sheldon Newman et al AJO 2001

• Exposure time
40 secs - conventional curing light
3 , 6 , & 9 secs – xenon plasma light
• Bond strength
xenon light > with longer exposure time
• To equal bond strength of conventional curing light the exposure time with xenon
had to be 6 –9 seconds

Light emitting diode curing units

Mills –1995
• Instead of hot filament – Halogen bulb.
• LED – junction of doped semi conductors.
Advantages;
• Lifetime 10, 000 hrs
• Requires no filters
• Resist shock and vibration
• Little power to operate
• Newer –GALLIUM NITRIDE ( LED )
400-500microns
 • Optimum curing time ?
• Replace halogen bulbs ?
Mills et al ( BJO 1997 )
• Compared light source containing LED to Halogen units
• Concluded – LED curing units cured composites to significantly greater depths
when tested at 40 & 60 sec

Polymerization of resin cement with LED curing unit

William Dunn & Louis Taloumis
AJO sep 2002
• Compared the shear bond strength of orthodontic brackets bonded to teeth with
conventional halogen light and LED curing units .
• Concluded- LED curing units bonded brackets to enamel as well as Halogen
based curing lights

Pulsed Xenon Plasma Arc Light

Polymerization shrinkage – Over come
-Curing composite in layers
-Pulsed curing light
Pulsed curing light- unit light is a series of pulse to polymerize the adhesive

Facts
• In the study by Eliades et al the DC value for a light cured adhesive bonded to a
metal bracket and irradiated from incisal & cervical edges was comparable to DC
values for a chemically cured adhesive & its light cured counterpart bonded to
ceramic brackets
• J Dent Res 1992 (sp Issue) 71:169

Bikram S Thind & David R Stirrups ( EJO 2006) compared tungsten quartz halogen,
plasma arc and LED light sources for polymerization of an orthodontic adhesive and
concluded that polymerization as effective as conventional bulb light sources was
obtained with short exposure times recommended for plasma arc or LED

Similar results have been got for Argon laser (Bryan S, Angle Orthod 2006) where it is
concluded that exposure time beyond 5 sec and power setting beyond 150mW has no
cumulative effect on the shear bond strength of stainless steel orthodontic brackets.

• The concept of ―total energy,‖— the reciprocity between power density and
exposure
• The concept of ―total energy‖ does not hold for orthodontic light-cure bracket
bonding. An exposure time of less than 4 seconds, irrespective of the power
density, cannot guarantee sufficient bracket bond strength. There seems to be an
 advantage of power density over exposure duration in the context of metallic
bracket bonding.
Am J Orthod Dentofacial Orthop Oct 2008;134:543-7
These results show that, for an efficient light-cure bracket bonding, there is an absolute
lower limit of exposure duration (4 seconds) and an upper limit of useful power density
(3000 mW/cm2).
• 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.

• Reynolds and von Fraunhofer (1976) investigated the minimum bond strength
values required in direct orthodontic bonding systems with bracket placement and
confirmed that bond strengths of
5.9 – 7.8 MPa are clinically acceptable.

Various Factors Can Affect Bond Failure

1. operator technique and manual dexterity,
2. patient behaviour,
3. variation in the enamel surface,
4. the type of etchant used
5. its duration of application,
6. the adhesive Influence of different tooth types on the bond strength

• Mattick and Hobson (2000) showed that the etched enamel surface varied
between different tooth types => influence bond strength.
• Linklater and Gordon (2001) and Hobson et al. (2001) => significant differences
in the bond strength of different tooth types
• no significant differences between upper and lower teeth of the same type (
Linklater and Gordon, 2001 ).
European Journal of Orthodontics 30 (2008) 407–412

A post-treatment evaluation, after 9-20 months of routine orthodontic therapy

Bjorn U. Zachrisson (EJO 2007)
• overall failure rate = 11 per cent
• The brackets most prone to come loose, maxillary first molars =27%
• mandibular first molars = 24%
• Mandi. second molars = 18% molars.
• all other teeth = lower than 10 %
• canines = lowest debonding rates (4-6%)
 Bonding to Molar-
In young patients second molars bonding is advantageous.
Resin modified GIC (chemical & light cured)- bond to saliva contaminated enamel
surface without phosphoric acid etching
Liquid- Polyacrylic acid, maleic acid
It removes contaminants & change surface mechanically
It do not produce micromechanical retention.
Disadvantages-
 1. Do not create micromechanical retention as good as 37% phosphoric acid.
 2. Bond strength is lower.

Bonding to Premolar-
-Most difficult technical problem
-Visibility - mouth mirror is recommended.
-Newly erupted mandibular premolar gingivally offset brackets
are recommended.
•

Ligation of Bonded Brackets-

 Bonded brackets will not withstand heavy pull on arch wires.
Steel ties are safer than elastomers & definitely are more hygienic.
Rule of Thumb - ligature wire should be twisted with the strand that crosses arch wire
closest to bracket wing. This tightens ligature when end is tucked under arch wire.
- Push arch wire into bottom of slot using fingers for flexible wires & plier or
ligature director for stiffer wire & make passive ligation.
- If full engagement is not possible, ligature can be retied at next visit.
•
Ligature less, self ligating, low friction brackets are available now- SPEED system
Advantages-
a. Saves time.
b. Reduces friction.
c. Increases patient comfort

• First Direct bonding

It was done in Eastman Dental Center in 1966
Round metal brackets with single groove 0.019×0.025 inch slot were used
Adhesive was Plastic resin base with liquid monomer of methyl-2-cyanoacrylate &
silicate filler
 Working time- 1 min
 ST- 2-4 min
•
Acid Etching- 50% phosphoric acid & 7% zinc oxide- 45 secs
- Only 4 upper anterior teeth bonded
- In few cases canines were bonded
- Arch wires placed in next visit
BRACKETS-
1. Plastic Brackets-
They are made up of polycarbonate & are used mainly for esthetic purpose.
Pure plastic brackets lack strength to resist distortion & breakages, wire slot wear, uptake
of water, discoloration, & need for compatible bonding resin.
Such brackets may be useful in minimal force situation & for treatment of short duration.
New types of reinforced plastic brackets with or without steel slot inserts have presently
being introduced.

2. Ceramic Brackets-
Theoretically porcelain brackets made of aluminum oxide could combine esthetics of
plastic & reliability of metal brackets.
Two forms currently available are-
1. Polycrystalline- Made of sintered or fused aluminum oxide particles.
Eg- GAC Allure, Unitek 3M Transcend 2000.
2. Single crystal form-‗A‘ company starfire.
Both of them resists staining & discoloration.

Ceramic brackets bond to enamel by 2 mechanisms-

a. Mechanical retention via indentation &b undercuts in the base.
b. Chemical bonding by means of silane coupling agent.
With mechanical retention the stress of debonding is generally at adhesive bracket
interface, whereas chemical bonding may produce excessive bond strength with stress at
debonding shifted towards enamel-adhesive interface.

Drawbacks-
1. Frictional resistance between orthodontic wire & ceramic bracket is greater & less
predictable than with steel brackets therefore optimal force levels & anchorage control
are difficult to determine.
2. Not as durable as steel brackets & brittle by nature( break easily)
3. Harder than steel & induce enamel wear of any opposing teeth.
4. Debonding is difficult- wing fractures easily.
5. Surface is more rougher & more porous attracts plaque & stains surrounding enamel.
6. Added bulk required to provide adequate strength makes oral hygiene difficult.

3. Metal Brackets-
Although not as esthetically pleasing as ceramic & plastic brackets , small metal
attachments are improvement over bands metal brackets rely on mechanical retention for
bonding & mesh gauge is conventional method of providing retention. Photoetched
recessions or machined undercuts are also available.
The base of the bracket must be small ( not smaller than bracket wings therefore of
danger of demineralization around periphery) as it avoids gingival irritation & should be
designed to follow tissue contour along gingival margin.
Corrosion of metal is a problem & black & green stains appeared with bonded stainless
steel attachments. Hence increased interest fore corrosion resistant & biocompatible
brackets like titanium.
4.Gold coated Brackets-
- Used particularly for maxillary premolar, mandibular anterior & posterior teeth.
- More hygienic & neater.
- Corrosion is not found clinically

Adhesive Precoated Brackets

Advantages
1. Better control over
flash removal
2. Better slot orientation

3. Moisture tolerant
4. Better resin hygiene
5. Convenience

Clinical comparison of APC bracket v/s uncoated ceramic bracket

system
- Verstrynge et. al, OCFR 04
Materials & methods
RCT with APC Clarity® v/s Clarity®
+ Transbond XT®
20 pts. Requiring fixed mechanotherapy.
ARI at debonding was recorded.
Results
No significant diff. in ARI scores b/w the 2 groups.
The 2 groups performed identically.

INDIRECT BONDING-
Several techniques for indirect bonding are available. Most are based on procedures
based on procedures described by Silverman & Cohen. Most current indirect bonding
techniques are based on based on modification introduced by Thomas. In these
techniques brackets are attached to teeth on patients models, transferred to mouth with
some sort of tray into brackets become incorporated & then bonded simultaneously.
Advantages-
1. Brackets can be placed more accurately.
2. Clinical chair time is decreased.
Disadvantages-
1. Removal of excessive is more difficult & more time consuming.
2. Risk for adhesive deficiency under brackets is greater.
3. Failure rates are high.
4. Technique sensitive
5. Chairside procedure very crucial.
6. Risk of adhesive leakage to interproximal gingival areas.
Reasons for difference in bond strength between direct & indirect techniques-
1. Bracket bases may be fitted closer to tooth surface with one point fitting by placement
scaler than when a transfer tray is placed over teeth.
2. A totally undisturbed setting is obtained more easily with direct bonding.

Several indirect bonding techniques have proved reliable in clinical practice. They differ
in way brackets are attached temporarily to model ( caramel candy, laboratory adhesive,
bonding resin), the type of transfer tray (silicone, acrylic with transfer arms) .

SILVERMAN AND COHEN – 1972

• MMA and UV light activated unfilled BISGMA
• MMA was applied to the plastic bracket base on the patient‘s model
• BISGMA –intermediary adhesive between the patients etched enamel & pre set
adhesive on the bracket base
• Updated technique – 1974 by same authors
• Used perforated metal bracket bases and only one adhesive- BISGMA[ UV light
activated]
• Increased operator working time as polymerization did not occur

THOMAS TECHNIQUE 1979

• Filled BISGMA resin placed into the bracket bases
• Attached to the stone model
• Before setting all excess material is removed from the cast around the brackets
• Transfer tray made of flexible material
• Tray + brackets removed from the cast as single unit
• Teeth of one arch isolated +etched
• Liquid unfilled resin formed the interface between etched enamel and filled resin
• Liquid catalyst – tooth
• Base resin – brackets
• Unfilled resin not pre mixed – working time increased
• tray seated held till polymerization is complete

Silicone Tray technique-

1. Make an impression & pour a stone model
2. Select brackets for each tooth
3. Apply a small portion of water soluble adhesive on each base or tootrh.
4. Position brackets on model. Check all measurements & alignments. Reposition if
needed.
5. For silicone tray fabrication , mix material . Press the putty onto cemented brackets.
Form a tray allowing sufficient thickness for strength.
6. After silicone has set, immerse model & tray in hot water to release the brackets from
stone. Remove any adhesive under running water.
7. Trim tray & mark midline
8. Prepare patients teeth as for direct bonding
9. Mix adhesive, load it in syringe. Apply a sufficient portion to bonding bases.
10. Seat tray on the prepared arch & hold with firm & steady pressure for about 3 mins.
11. Remove the tray after 10 mins. The tray may be cut transversly or longitudinally to
reduce the risk of bracket debonding when peeled.
12.Complete bonding by careful removal of excess flash. Use a scaler & oval or tapered
TC bur to clean tray properly around bracket
Above steps are shown in following figure-

Indirect bonding
Moin & Dogon technique AJO 1977
• Pour impression in stone
• A drop of sticky wax is placed on teeth surfaces of cast
Brackets are warmed over flame and set on the cast
• Impression made with polyether material
• Tray separated from cast but brackets remain in situ
• Bracket is removed from the cast &warmed to remove
residual wax
• They are placed into the impression
• Teeth are pumiced,etched & isolated
• Enamel surface is sealed with mixture of universal &
catalyst sealant
• bracket base is covered with the adhesive
• tray is seated
• Use of sticky wax-corrections can easily
&readily be made until optimal bracket
alignment is obtained
• Previously used
• Adhesive tape - bracket displacement
• Bonding resin – cleaning of bracket base prior to
bonding difficult and time consuming
A new approach to indirect bonding technique using light-cure
composites - AJO-DO 1997
- Paul Kasrovi et al
Conventional indirect bonding –
 Non-transparent trays
 Poor visualization
 Self-cure resin – difficult to clean-up on setting
 Time lost in removing set flash
 Improperly seated tray revealed only after removal – misplaced brackets, failed
procedures

• Modifies the fabrication of transfer tray

• Provides direct visualization & access to the brackets - during both lab and
clinical procedures
STEPS

• Lab adhesive for IDB

 Technique is highly predictable & reproducible
 Visibility and accessibility from start to finish
 Ability to remove composite flash before curing
Double sealant technique-
Steps-
1. Bonding adhesive paste – attach brackets to model
2. Excessive adhesive removed
3. After 10 min, placement tray is vaccum formed
4. Trays with model placed in water
5. Tray separated and trimmed with gingival edge within 2mm of brackets
6. Midline marked
7. Bonding base lightly abraded with stone point
8. Oral prophylaxis, isolation & etching
9. Tooth- Universal sealant resin
Bracket base- catalyst sealant resin
10. Tray seated - held for 3 mins
11. Peel it from lingual towards buccal
12. Remove excess
Advantages-
1. Clean up is simple
2. Little flash

• Composite Custom bracket base-

1.Make an impression & pour up a stone model.
2.Select brackets for each tooth.
3.Isolate stone model with a separating medium.
4.Attach brackets to teeth on model
5.Check all measurements & alignments. Reposition if needed.
6.Make transfer tray for brackets. Material can be putty silicone, thermoplastics or
similar.
7.Remove transfer tray & gently sandblast adhesive base with microetching unit.
8. Apply acetone to base to dissolve remaining separating medium.
9. Prepare patient teeth for a direct application.
10. Apply Sondhi Rapid Set resin A to teeth surface & resin B to bracket base. If Custom
IQ is used, apply resin B to teeth & resin A to bases
11. Seat tray on prepared arch & apply equal pressure to occlusal, labial & buccal
surface for 30 secs & allow 2 mins or more of curing.
12. Remove excess flash of resin with scaler or contrangle handpiece & tungsten carbide
bur.
Above steps are shown in following figure-
 • Resin used for Indirect Bonding contains fine particle fumed silica filler
which avoid voids
It has quick set time- 30secs which allows rapid removal of tray in 2mins

Indirect bonding technique- ANUP SONDHI

• Lab procedure-
1. Working models from accurate alginate impression
remove air voids
2. Apply thin layer of diluted separating medium
Dry for 1 hr
3. If APC brackets- place directly
If non-coated- Place Transbond XT adhesive on base
4. Place all brackets
5. Check for final bracket placement
6. Place models in TRIAD 2000 curing unit
7. Cure for 10 minutes
If clear esthetic brackets- cure for 1 min
8. Use light separating spray to fascilitate easy removal of tray from
brackets
Silicon/ light cooking spray like PAM.
Spray for less than 1 secs
9. Tray is made
Biostar unit- Vaccum formed tray with 1.5 mm thick layer of bio-
plast , overlayed with 0.75mm thick layer of Biocryl
Outer layer- rigidity
Inner layer- easier removal
10. Soak tray for 1 hour- separating medium dissolves
11. Tray sectioned with bur
12. Once trimmed place in TRID unit to ensure curing of uncured resin
13. Clean tray with ultrasonic cleaner with dishwashing detergent for 10 mins then with
water-for 5 mins
Microetching is done to remove any adhesive remnant

• Clinical steps-
1. Antisialagogue- atropine/ propantheline is given to decrease salivation
2. Polish teeth with pumice
3. Tray can either Single tray / segmented depending on the type of malocclusion
Segmented tray is used in case of crowding
4. Isolation
5. Dry teeth
6. Etching- 15secs
Suction gel off. Water sprayed 30secs
7. Apply primer, air dry for 2secs
8. Resin poured in wells. Apply resin A on tooth surface & resin B on
bracket base

9. Position tray & seat it in hinge motion. Apply equal pressure for
30 secs. It is cured for 2 mins

10. Remove outer layer using scaler

11. Remove inner layer using scaler & fingers
12. Scale excess resin & floss interproximal areas
 Flowable Light-Cured Adhesive
• PETER G. MILES JCO2002
Apc brackets used

A Thermal-Cured, Fluoride-Releasing Indirect Bonding

System
• R .S. Nanda, P.K. Sinha JCO 1995
• Heat the cast with the brackets in place in a countertop toaster-oven, set at 325°F,
for 20 minutes. This process will cure the composite resin. Calibrate the oven
thermostat monthly with an oven thermometer. Remove the model from the oven,
and let it cool. .
Make a transfer tray from silicone impression material or a vacuum-formed plastic sheet.
We prefer the silicone material, which is manipulated to encapsulate the brackets and
make an impression of the model. This allows all the brackets to be bonded
simultaneously in their predetermined positions.

Mix Maxicure* sealants \ and B Th

sealant, which contains hydrogen fluoride m >S
monomer, reaches its initial set in 60 second* and therefore no time should be wasted
once n has been mixed.

Indirect Bonding with

a Thermal Cured Composite
Elliott M. Moskowitz
• modification of the Thomas technique
1. Thermally cured composite material.
2. Reprosil—a vinyl polysiloxane impression material (PVS) as a highly accurate but
flexible inner tray that can be easily removed.
3. Vacuum-form Essix 0.020 inch (0.5 mm) clear material tray that covers the PVS inner
tray

Place the ThermaCure composite resin on

the pad of each bracket, taking care to cover
all of the pad surfaces. The
ThermaCure provides virtually unlimited
working time

Casts placed in toaster oven for curing at

325°F for 15 minutes
2. Apply the Reprosil impression material with
a syringe over the thermally cured brackets
3. Vacuum-form Essix (trademark of Raintree
Essix, Inc., New Orleans, LA) 0.020 inch
(0.5 mm) or 0.030 inch (0.75 mm) clear
thermoplastic material over the cast, brackets,
and undertray complex
 To remove the air-inhibited layer of adhesive,
lightly abrade the composite back of
each bracket base with a Micro Etcher
Mix 2 drops each of Enhance (Reliance
Orthodontic Products, Itasca, IL) A and B
primer. Apply the mixture to the composite
bases and the tooth surfaces.

The flexible undertray is teased away with

an explorer or scaler without dislodging the
brackets.

• Bond Strength-
Ratio of debonding force by interfacial area of adhesive or bracket base.
 Bonding area- 16mm2
 Debonding force- 120N
 Bond Strength- 7.5 N/mm2 or 7.5 MPa
 Able to withstand stress of 6-8 MPa
Various Factors Can Affect Bond Failure
1. operator technique and manual dexterity,
2. patient behaviour,
3. variation in the enamel surface,
4. the type of etchant used
5. its duration of application,
6. the adhesive Influence of different tooth types on the bond strength

• Mattick and Hobson (2000) showed that the etched enamel surface varied
between different tooth types => influence bond strength.
• Linklater and Gordon (2001) and Hobson et al. (2001) => significant differences
in the bond strength of different tooth types
• no significant differences between upper and lower teeth of the same type (
Linklater and Gordon, 2001 ).
European Journal of Orthodontics 30 (2008) 407–412

A post-treatment evaluation, after 9-20 months of routine orthodontic therapy

Bjorn U. Zachrisson (EJO 2007)
• overall failure rate = 11 per cent
• The brackets most prone to come loose, maxillary first molars =27%
• mandibular first molars = 24%
• Mandi. second molars = 18% molars.
• all other teeth = lower than 10 %
• canines = lowest debonding rates (4-6%)

• Lingual Orthodontics
LINGUAL BRACKET POSITIONING ( INVISIBLE RETAINERS)

Lingual orthodontics has added a new dimension to bonding spectrum, however

questions have arisen with regard to lingual bonding procedures & how, if at all they
should differ from labial bonding procedures.
The technique rapidly gained popularity in early 1980‘s, but most clinicians
experienced considerable difficulties particularly in finishing stages & abandoned the
technique for routine use.
The development was pioneered in Japan by Fujita who worked on
mushroom arch, & by several American orthodontists: Kurz, Kelley &
more recently by Creekmore. Although it appears possible to treat
malocclusion successfully from lingual side, a combined lingual & buccal
segmental approach may offer a number of options with no great esthetic
compromises n most patients.
- More precision is necessary for adjustment of lingual arch wires with
reduced bracket distance.
- If lingual treatment is to become more important in future, additional
improvements in bracket design & technical aids are needed.
 - Pronunciations difficulty occur immediately after insertion.
- Difficult & time consuming.
- Working position awkward.

Customized brackets are formed after scanning malocclusion model

using a high resolution optical 3-D scanner. Brackets then designed in
computer using computer aided manufacturing technology. High end
rapid prototyping machines are used to convert virtual bracket series
into wax analog that is then casted into alloy with high gold content.

• BONDING TO OTHER METALS-

Many adult patients have crown & bridge restorations fabricated from porcelain & non-
precious metals or gold. Recent advances in materials & techniques indicate however that
effective bonding of orthodontic attachments to surface other than enamel may now be
possible

.
Intraoral Sandblasting-
Microetcher - Uses 50µm white or 90µm tan aluminum oxide at 7kg/cm2 pressure
Uses-
-Rebonding loose bracket
-Increases retentive area inside molar band
-Create retention for bonded retainers
- Bonding to decidous teeth.

BONDING TO PORCELAIN-
In 1986 Wood et al showed that roughening the porcelain surface, adding a porcelain
primer & using a highly filled adhesive resin when bonding to glazed porcelain added
progressively to bond strength.
In vitro studies have shown that bond strength to porcelain equals or surpassed that
obtained after bonding to acid etched enamel which suggested possible damage to
porcelain tooth surface during debonding.
Two different techniques-
1. Hydrofluoric acid gel – Excellent result
2. Sandblasting & silane (Scotchprime)
3. Others-
Roughninig with diamonds or stones

1. Conventional acid etching is ineffective in preparation of porcelain surfaces for

mechanical retention of brackets. However , several porcelain etchants have been
developed. The most commonly used etchant is 9.6% Hydrofluoric acid. In gel form for 2
to 4 mins.
Hydrofluoric acid is strong & requires careful isolation of working area, cautious
removal of gel with cotton roll, rinsing with high volume suction & immediate drying &
bonding.
Etchant produces microporosities on porcelain surface that achieves mechanical
retention. Etchant porcelain will have frosted appearance similar to etched enamel.
Other studies indicate that 1.23% or 4% Acidulated Phosphate Fluoride(APF) for
10 mins solution or gel containing sodium fluoride, phosphoric acid & hydrofluoric acid
may provide equivalent bond strength.
Procedure-
1. Isolate working field adequately.
2. Use barrier gel such as Kool-Dam to prevent flow of gel in gingiva or soft tissues.
3. Deglaze area slightly larger than bracket by sandblasting with
50Mm aluminum oxide for 3 secs.
4.Etch porcelain with 9.6% hydrofluoric acid gel for 2 mins.
5. Remove gel with cotton roll & rinse using high volume suction.
6. Immediately dry with air & bond bracket.

2. Porcelain surface is sandblasted with aluminum oxide to create

rough surface
If allergic to Al.oxide- Silicon carbide
Silane coupling - γ-methacryloxy-propyltrimethoxysilane which provides reactive sites
for inorganic & organic components.
Methacrylate groups- covalent bond with polymer matrix
Hydrofluoric acid cannot be used for high alumina porcelain & glass ceramics where
silica coating can be used.
•
Debonding-
 Gentle 45 degree outward pull applied to gingival tie wings
 Residual adhesive- remove with tungstun carbide bur
 Smoothing- slow speed polishing rubber wheel
 Polishing- Diamond polishing paste in rubber cup

• Surface preparation for orthodontic bonding to porcelain

ZACHRISSON et al AJO 1996
HF acid gel = sand blasting + silane
• Some authors feel
Sand blasting + silane = high failure rates
AJO-DO 1998 Zachrisson showed HF produce extensive in depth penetrating pattern
.But diamond roughening & microetching produce only surface peeling.
AJO –DO 2004 Mutlu Ozean et al superior bond strength is obtained when ceramic
surface is pretreated with silica coating & silanization giving about 13.6 MPa particularly
with polycarbonate brackets. Bond failure site is at bracket / adhesive interface.

•
BONDING TO AMALGAM-
Techniques for bonding to amalgam includes-

1) The method of choice for bonding to hardened amalgam with any orthodontic adhesive
is to increase surface by sand blasting.
2) Intermediate resin that improves bond strength- All Bond 2
3) Adhesive resin that bond chemically to metals- 4-methacryloxtethyl trimellitate
anhydride (4-META) & 10-MDP /Bis-GMA resins.
Strongest bond to amalgam were obtained with 4-META adhesive9Superbond C & B)

Procedure-
For small amalgam fillings-
1. Sandblast amalgam with 50Mm aluminum oxide for 3 secs.
2. Condition surrounding enamel with 37% phosphoric acid for
15 secs.
3. Apply sealant & bond with composite.

For Large amalgam fillings-

1. Sandblast amalgam with 50Mm aluminum oxide for 3 secs.
2. Apply a uniform coat of Reliance metal primer & wait for 30 secs.
3. Apply sealant & bond with composite.
•
• BONDING TO GOLD-
Until recently bonding to gold & other metals was considered difficult. In 1980‘s some
adhesives ( Enamelite 500, Goldlink) & primers (Fusion) were designed to allow such
bonding however published reports & clinical experience do not support their
effectiveness.
Roughening gold surface with green stone was found by Wood et al to significantly
increase bond strength to a highly filled resin system. However the breakthrough came
with intraoral sandblasting. A hand piece abraded surface may look rough eye, but SEM
studies indicate that micromechanical retention of metals can be increased by atleast
300% using intraoral sandblasting.
The micro etcher which uses 50 micron while aluminum oxide or
silicon carbide particles approximately 7kg/cm2 pressure has been most
advantageous for bonding to gold & other metals. During a quick 3
second blast with fingertip control & high speed evacuation the
abrasives creates a retentive surface to which bonding & composite resin
(Concise) is greatly enhanced.
Tin Plating-
New voltage tin plates also facilitate intraoral bonding to noble metals. The deposition of
layer of tin on gold surface permits a chemical & mechanical bond between resin &
metal.
Most commonly the tin is electrolytically deposited with a unit such as Micro Tin or
Kura Ace Mini.
Tin plating is not approved by Food & Drug administration for intraoral use.
Alternative method is to rub on a solution of gallium Or tin alloy with a pure tin bar.

Alternative that bond chemically to Metal-

1. Two different types of adhesives 4-META resins ( Methacryloethyl trimellitate
anhydro) & 10-MDP bisGMA have been recently developed to improve adhesion to
metals.
2. Super bond C & B is activated by combining 4-META & tributyl borane monomers &
then adding polymer powder to activated liquid.
3. Bond strength of any adhesive can be greatly increased by with intermediate resins
like All-Bond 2+ and Scotchbond MP (multipurpose).

Gloria Nollie et al in ANGLE 1997 reported that Type –1V gold treated with adlloy
has increased bond strength & gives twice as strong as those found in microetched gold.

BONDING TO COMPOSITES-
1.Outer layer removed with diamond /carbide bur
2. Etch- 37% phosphoric acid
3. Apply silane coupling agent
4. Bonding
•
BONDING TO ACRYLICS-
- Wet surface with MMA for 3 mins
- Bond using unfilled resin & composite

Deciduous teeth
• The outer prismless enamel layer
• lacks the characteristic prism markings of enamel
• no well-developed etch pattern with well-defined prisms
• The enamel crystallite diameter of deciduous teeth is relatively larger than
permanent teeth
• The chemical compositions of calcium and phosphorus => similar

• A recommended procedure for conditioning deciduous teeth ==

• sandblast with 50-μm aluminum oxide for 3 seconds to remove some outermost
aprismatic enamel
 • etch for 30 seconds with the Ultraetch 35% phosphoric acid gel.
• The failure rate = less than 5%.

• Comparison of shear bond strengths of orthodontic brackets bonded to deciduous

and permanent teeth
Toshiya Endo AJO 2008 Aug
4 groups:
a. Permanent teeth – acid etch tech.
b. Permanent teeth – SEP
c. Deciduous teeth – acid etch
d. Deciduous teeth – SEP
Results =
The shear bond strengths of the brackets bonded to the deciduous teeth with either
adhesive system were lower than those to the permanent teeth
SBS for all groups exceeded the clinically sufficient SBS i.e. 6 to 8 MPa

Enamel Fluorosis
• Fluorosed enamel =
• an outer hypermineralized and acid-resistant layer
• difficult to attach bonds because a reliable etched enamel surface cannot be
produced.
• Fluorosis manifests itself as defects in the subsurface enamel
As
• colour from white to brown
• as pits and irregular white opaque lines
• striations
cloudy areas

• Effects of adhesion promoters on the shear bond strengths of orthodontic

brackets to fluorosed enamel
Necdet Adanir et al EJO Dec 2008
evaluate the effect of enamel fluorosis on the SBS of orthodontic brackets and to
determine whether adhesion promoter, Enhance LC, increases the bond strength of
brackets to fluorosed enamel.

• Results =
• fluorosis significantly reduced the bond strengths
• Enhance LC significantly increased bond strength on fluorosed enamel

In Vivo Bonding of Orthodontic Brackets to Fluorosed Enamel

using an Adhesion Promotor
James Noble et al AO 2008
• the success of bracket retention using an adhesion promoter with and without the
additional microabrasion of enamel.
 • group 1 – microabrasion + acid etching + Scotchbond Multipurpose Plus Bonding
Adhesive
• Group 2 – acid etching + Scotchbond Multipurpose Plus Bonding Adhesive

• Conclusion
• Bonding orthodontic attachments to fluorosed enamel using an adhesion promoter
is a viable clinical procedure that does not require the additional micro-
mechanical abrasion step.
 Miller JCO 1995 reported that microabrasion of fluorosed enamel concomitantly
with acid etching improves bond strength

• Rebonding
-Consumes more chair time
- It can be avoided by following rules for bonding
Procedure-
- Remove from archwire
- Remove adhesive from tooth surface with tungstun carbide bur
- Sandblast bracket
- Re-etch tooth surface for 15 secs.
Loose ceramic bracket- better to replace with new for optimal bond strength.

Optimization of a procedure for rebonding dislodged orthodontic brackets

B. Mui et al AO 1999
Compared shear bond strength (SBS) of bonded and rebonded orthodontic
brackets
Brackets debonded were rebonded after the removal of residual resin from
enamel surfaces using five different treatments
(1) Remove residual resin using a tungsten carbide bur, re-etch enamel surface, then
bond a new bracket
(2) ) Remove resin from the base mesh with micro-etching then rebond the same
bracket
(3) (3) Remove residual resin from the enamel surface using resin-removing pliers,
recondition the enamel with an air-powder polisher, then bond a new bracket
(4) (4) Remove residual resin using a rubber cup and pumice, then bond a new
bracket
(5) (5) Remove residual resin using pliers alone, then bond a new bracket.
(6) results =>
the light-cured system produced higher shear bond strength in the initial
bond than the self-cured system.
Reconditioning the enamel surfaces using a tungsten carbide bur and
acid-etching gave the highest SBS (difference 5.8 MPa; p<0.01) and clinically
favorable fracture characteristics.
 • The optimal procedure for rebonding dislodged orthodontic brackets is to
resurface the enamel using a tungsten carbide bur, acid-etch the enamel, and use
a new or re-use an old bracket after microetching.

• Recycling-
Goal- remove adhesive from bracket without damaging bracket backing /distorting
dimensions of slot.
Only 4% of orthodontists in US use recycled brackets
Methods-
 1. Heat (above 450) to burn resin followed by electropoloshing to remove oxide build
up
 2. Solvent striping with high frequency vibrations & flash electropolishing
 Electropolishing- Remove tarnish or oxide
 Buchman- Changes in torque angle & slot size after 1/2 recycling were below
significance.

• Frictional Effects between bracket & arch wire-

Friction at interface between wire & bracket produces resistance to movement. It is
directly proportional to force at which contacting surfaces are pressed together.

Affected by nature of surface-

Rough/smooth
Reactive/passive
Though surface appears to be smooth microscopic irregularites present
Real contact occurs only at limited no of spots at peak of irregularity ASPERITES which
-Carry all loads
- Light load- cause appreciable plastic deformation
When force is applied- junctions shears as sliding takes place
When soft material slides against harder, small fragments of soft
material adheres to hard one

• Friction depends on -
1. Surface qualities of wires-
NiTi- greater surface roughness
Beta-Ti – greater frictional resistance
Cold weld to steel bracket – sliding impossible.

2. Brackets-
 Steel –smooth
 Titanium – sliding difficult
 Ceramic –
Rough & hard
Can penetrate steel wires during sliding
Produces nicks & cuts in wire
To reduce friction metal slot can be used
•
3.Force of contact-
- If tooth pulled along arch wire-initial tipping
- Friction based on contact angle at which corner of the
bracket meets arch wire. More the angle, more is the
friction.
•
Self ligating - reduced friction- effective sliding-better
anchorage control

APPLICATIONS OF BONDING-

1. BONDED RETAINERS-
Advantages-
1. Differential retention
2. Completely invisible from front
3. Reduced caries risk
4. Reduced need for long term patient co-operation.
5. Prolonged semi permanent as well as even permanent retention when conventional
retainers do not provide same degree of stability
•
Differential Retention-
Introduced by James L. Jensen, implies special attention is directed towards the strongest
or most important predilection site for relapse in each & every case.

Based on evaluation of-

Pre-treatment records
Habits
Patient cooperation
Growth pattern
Age

• Types-
 Mandibular canine to Canine retainers
 Mandibular premolar to premolar retainer
 Direct contact splinting
 Flexible spiral wire retainers
 Hold retainers for individual tooth
•
Made of -
 Thick wire- 0.030/0.032 inch
 Thin wire- 0.0215 inch

DIRECT CONTACT SPLINTING-

- Prevent post orthodontic space opening & stability against traumatic jigging
- Absolute moisture control is very important- rubber dam
- Toothpicks to avoid interdental flow of adhesive
- Bond breakage high- Need for independent physiological tooth
movement during function
•
BONDED SPACE MAITAINERS –

Several studies regarding bonded space maintainers have been described with varying
degree of short term success. Long term results on a group of
patients are not available for any design.
They are made of 0.032 inch s. steel wire/ 0.030 gold coated wire.
Utility wire design was used to reduce the influence of occlusal
forces

BONDED SINGLE TOOTH REPLACEMENT –

For most children having missing anterior teeth, replacement is made mainly by
removable appliance. Such appliances are sometimes damaging to periodontal tissues &
an inconvenience to patient.
Use of acid etched retainers cast appliances has been expanded to include other
appliances including posterior tooth replacement & tooth contouring.
Another method which is cheaper, simpler & more durable than cast variant for anterior
tooth replacement is by using acrylic prosthetic tooth & inserting into it 2 flexible braided
rectangular (0.016×0.022) & one round spiral wire (0.0195) for support.
Short clinical crowns can be utilized since rectangular braided wire is placed along
gingival margin. With round wire on either side & thus
frequently out of occlusion.
This type of replacement can be used during
orthodontic treatment. It can be attached to canine or
second premolar for better esthetics to avoid empty –
looking spaces in adults when premolar extractions are needed & invisible lingual
appliances are used.

•
SPLINTING OF TRAUMATIC INJURIES-

The goal of splinting traumatized teeth is to stabilize & to allow healing & prevent
further damage to pulp & periodontal structures.
Several types of traumatic splinting devices are conventionally used including band –
acrylic splint, contact splinting with composite & orthodontic bonded bracket plus arch
wire.
It has been demonstrated that clinical success has been achieved by using bonded plastic
wire and thick 0.032 inch stainless steel spiral wire.

COMPOSITE BUILDUPS-
The addition of composite resin to non- carious teeth during or after orthodontic
treatment may be indicated as an alternative to capping on single or multiple teeth to
solve tooth shape & / size problems.
In certain situations this buildup technique may be provide esthetic improvement of the
orthodontic results. Eg.- small or peg shaped lateral, congenitally missing lateral.

As shown in below figure restoration of peg lateral to normal size & shape.

• DEBONDING-

Definition:
To remove the attachment and all the adhesive resin from the tooth and restore the
surface as closely as possible to its pre-treatment condition without inducing iatrogenic
damage.

Objectives-

 Remove attachment & all adhesive resin from tooth surface

 Restore surface as closely as possible to its pre treatment condition

DEBONDING OF BRACKETS:
Principles:
1. Minimum damage to enamel – fracture
• Within bonding material itself
• Between bracket – resin – most desirable
• Between resin – enamel - undesirable
2. Failure has to be induced between bracket and resin
3. Distorting metal bracket base – non-reusable
4. Remaining adhesive cleaned-up
5. Debonding ceramic brackets problematic
6. Bracket bases cannot be distorted
• Grind brackets – rotary instruments
• Mechanical instead of chemical bond between base and
resin
• Heat to soften resin, for easy removal – electrothermal /
lasers

Debonding Force
• In units Newton's (N), kilograms (kg), or pounds (lb).
• Bond strength= the force of debonding
the area of the bonded interface, Unit - megapascals grams per square
centimeter.
An adhesive-bracket system should be able to withstand a stress of at least 6-8MPa

PROCEDURE
Steel brackets-
1. Cutting -
-Tips of twin beaked plier against mesial & distal edges of bracket
& cut bracket off with peel force
•
2. Sqeezing-
- Sqeeze bracket wing mesiodistally & lift it with peeling force
Adv- Useful on brittle, mobile or endodontically treated teeth
Disadvantages-
 Brackets easily deformed
 Break at adhesive-bracket interface- adhesive remnant on
enamel
•
3. Peeling-
-Brackets gripped with removing plier & lifted outwards
at 45 angle
-It creates Peripheral stress concentration
-Advantage includes bracket remains intact & fit for
recycling

• Lift-off Debonding Instrument:

• A tensile force is placed on the adhesive bond through a wire loop hooked over
the bracket tie wings
• pulling the wings of the bracket directly away from the tooth surface.
• This method distorts the brackets the least and is preferred if recycling is a
consideration.

• Oliver and Pal (AJODO July 1989)

compared three methods of debonding:
• Method A— The mesial and distal wings of an edgewise twin bracket are
squeezed together with pliers.

• Method B— A shear force is applied with the blades of the debonding pliers or
ligature cutters positioned at the enamel/composite or composite/bracket
interface.
• Method C—
Use of LODI.
This may be used in two ways:
the arch wire – in situ
the slot keeper (a length of 0.018 ´ 0.022-inch wire embedded in a plastic handle)
In either case, the presence of a wire in the bracket should help to maintain the
slot dimensions.
• Results :
• Method B => most distortion (majority on the base).
• Method A => All parts equally affected
• Method C => wing distortion only.
• Most of the debonded brackets had increased slot dimensions compared with
control brackets, the greatest being an increase of 0.032 mm.
• The clinical significance (increase in slot dimension) => loss of effective torque
from an arch wire.
 • Conclusion –
Recycling of brackets is considered, then use of the lift off debracketing
instrument for bracket removal is most advantageous.

• Coley-Smith and Rock (BJO 1999) compared two methods of debonding (bracket
removing pliers or a lift off debonding instrument) in 507 metallic brackets, with
and without the archwire in place during debonding.
• After debond brackets were tested for slot closure by the fit of rectangular test
wires from 0·016X 0·022 to 0·021X 0·025 inch in size.
• Results :
• LODI produced few slot closures
• Bracket removing pliers used after removal of the archwire produced significantly
greater numbers of slot closures and distorted brackets.
• 10% of the brackets debonded using bracket removing pliers had distorted bases
• No base damage – LODI
When bracket removing pliers are used, the archwire should be left in place at the time of
debond since this reduces the number of distortions

• Ceramic brackets-
Ceramic – low fracture toughness
Metal deform- 20% under stress before fracture
Ceramic - < 1% before fracture
Common site of fracture - enamel-adhesive interface but metal bracket –adhesive
interface
Ripley- If retention is
 Chemical & mechanical- fracture occurs at Enamel –Adhesive interface
 Chemical- Bracket - fracture occurs at Adhesive interface
•
Reasons for failure during debonding is-
Stress incorporated during-
Ligation & arch wire activation
Force of mastication & occlusion
Stress applied during debonding

It creates cracks resulting in failure

• Methods of Debonding-
1. Mechanical
 Pliers-
ETM 346 direct bond bracket removing plier

Transcend debonding wrench

-Sharp torsional force applied in downward direction
-Very painful
-Risk of bracket failure hence Bracket remains on tooth surface where removal in high
speed handpiece
-Time consuming
-Ceramic dust – itching, eye irritation hence safety glass should be worn.

• Bishara et al (AJODO 1999) compared the debonding characteristics of the two

brackets, using their appropriate pliers.
The most efficient method of debonding the Clarity bracket is to use the Weingart pliers
and apply pressure to the tiewings
The most efficient method to debond the MXi ceramic bracket is to place the blades of
the ETM 346 plier between the bracket base and the enamel surface.
• The mean shear bond strength
Clarity bracket (10.4MPa) >
MXi ceramic bracket (7.6 MPa).
• Clinically acceptable
• The Clarity brackets – greater rate of partial bracket failure with the Weingart
pliers compared the to the MXi brackets in which no failures were seen.

•
2. Ultrasonic-
- Straight chisel tip with bevel of chisel towards bracket
- Flash- remove it before bracket removal
- Tip moved in MD direction until purchase pt / groove of 0.5 mm
made between bracket base & enamel surface
- Rocking motion applied to break bond
Advantages-
 No bracket breakage
 Can be used for metal brackets
 Less time
•
3. Electrothermal debonding (ETD)
- Heat used 3-0 joules total energy
- Given by Sheridan et al in 1986
- Rechargable direct current power unit connected to cylindrical
handpiece which ngets activated at 450ºF
- Debondig tip maintains constant temperature
- Width of tip is equal to width of vertical slot / saddle between M &
D tie wings of bracket
- When heat applied- it deforms Adhesive- Bracket interface &
bracket can be gently separated
 Time- 3.2 secs
 Composite softens – 300-392ºF
Bracket failure-
 Complete- tie wing
break at bracket base
within body of bracket
 Partial- fracture of bracket component in which part of bracket remains on tooth
surface
•
 Paul Takle et al –Studied pulpal response, debonding time & pt response to ETD
AJO 1995
Conclusions were-
 Pulpal hyperemia occurs 24 after debonding
 Upto 30 days- inflammation to pulpal fibrosis persists
 No discomfort except for burning smell
 5 secs application – irreversible pulpal disease.
•
Advantages-
 Better bracket removal without damage to enamel/ distortion of bracket
 Failure site- E- A interface
 Recyling of bracket
 Comfortable

Disadvantages-
 Pulpal damage
 Adhesive remains on tooth surface
 Burning smell
 Straight handpiece- intraoral use difficult

• Jost-Brinkmann et al (EJO 1997) did an in vivo study in which 12 human

premolars scheduled for extraction were bonded with ceramic brackets which
were subsequently debonded using ETD.
• After 4 weeks, the teeth were extracted and histologically examined.
• No signs of pulpal inflammation were seen.

•
4. Chemical debonding
Various chemicals used are-Acetone, Ethanol, Peppermint oil
 Peppermint oil – viscous gel in 2ml syringe
 Apply around bracket base & left for 2 min
 Promotes failure at Enamel –Adhesive interface
 No damage tooth
 Reduces mean & maximal debond force from 103.7, 200N to 77 & 114N
respectively.
 •
5. Laser debonding
 Ruby laser – first introduced in 1960‘s
 Widely used in dentistry
 Tocchio et al- degrades adhesive by 3 ways
1. Thermal softening- bracket slides off
Slow
•
2. Thermal ablation- heating is very fast to raise the temperature of resin into vapours
It is rapid as bracket blown off

3. Photoablation- High energy laser interact with adhesive & energy level bonds between
resin rises rapidly above their dissociation energy level resulting in decomposition of
adhesive.
Bracket-blown off from tooth surface.

•
CO2 laser timing-
 Super pulse- 2W for , <4 secs
 Normal pulse- little more time

Pulp- heat propagation can result in pulp damage

It is found that 5.5ºC raise can result in necrosis but results shows that there is increase of
 0.91ºC- after 1 sec of lasing
 1.74ºC- 2 secs
 2.67ºC- 3 secs

•
Ma et al – Debonding at 1.48 MPa of tensile load with CO2 laser at 18 W for 2 secs
 Intrapulpal temp raise of 1.1ºC
 Shear force to debond is less if MMA is used than BisGMA
•
Study by Samir Bishara - AJO 1992
Studied the 2 types of lasers-CO2 & Nd:YAG Laser
- Polycrystalline & monocrystalline brackets
Results-
- Polycrystalline- force decreased by factor by 25- CO2 laser at 14 watts for 2 secs
& there was complete bracket removal
- Monocrystalline- force decreased by factor of 5.2 at 7 watts
& Bracket cracked along slot in 2 of 10 cases
•
Advantages-
 Heat is localized & controlled
 Debracketing tool is cold
 Can be used for various types of brackets- all designs
 Atraumatic & safer
 •
6. Debonding With rubber dam-
- R.A.C.chate et al- safeguard during debonding as it
- Prevents inhalation/ingestion of fragments
- Isolation
Disadvantages-
- Gingival trauma due to inappropriate clamp application
- Respiratory distress – cannot be used in atopic individuals

•
•
7. Arthur Wool-
He suggested hot water rinse before debonding
- Used Small wood burning pen which has cool cork handle, plugs into a 110 volt outlet
- Flat , beveled, angled working tip
- 21 watts, generates 600ºC of heat
- Tip placed flat against facial aspect of bracket for 6-8 secs
- Patient indicates first feel of warmth- bracket removed with flat beaked
plier
•
Advantages-
 Safe
 Can be used for both metal & ceramic brackets
 No pulpal reactions

RESIDUAL ADHESIVE REMOVAL-

 Difficult- color similarity between adhesive & tooth.
 Abrasive wear minimal
 Remnants gets discolored over period of time

• Methods of removal-
1. Scrape with supersharp band/band removing plier/
scaler
- Fast & more useful on curved teeth
- Less use on flat anteriors
- Creates scratches
•
2. Suitable bur with contrangle
- Dome shaped tungstun carbide
- 30,000 rpm – rapid removal
- Light painting movements
- Water cooling is not recommended as it lessen contrast
 • Characterstics of Normal enamel –
1. Perikymata – transverse, wavelike grooves, parallel to each other which considered as
external manifestation of incremental lines of retzius.
2. Open enamel prism ends appear as small holes
Ridges get worn off- scratched pattern
•
As per Mannerberg-
 At 8 yrs- 1/3 – 2/3 surface
 At 13 yrs- reduced to 70-80%
 At 18 yrs- 25-50% ridges remains
 Normal wear- 0-2µm/year

• Enamel characterstics after debonding-

Zachrisson & Artun in 1979 – Enamel surface index which is based on
 Scanning electron microscopy
 Different instruments for debonding
•
Score 4 - diamond instruments
 Not acceptable
 Coarse scratches
 Marred appearance
•
Score 3 - medium sand paper disks & green rubber wheel
 Similar coarse appearance

•
Score 2 – fine sand paper disks
 Marked deeper scratches
 Surface resembles adult tooth

•
Score 1 – plain cut & spiral fluted TC bur
 At 25,000 rpm satisfactory appearane

Score 0 –
 None of instruments kept perikymata intact
•
Clinical implication-
 No instrument left surface intact
 TC spiral fluted bur- finest scratch pattern & has ability to reach difficult areas- pits,
fissures
 Lingual surfaces - Oval TC bur
 •
Ultrasonic scaler- alternative to burs
- Patient comfort
- Water coolant results in poor contrast
- Slow

• Amount of enamel lost in debonding-

Based on -
 Instrument used for prophylaxis
 Method of debonding
 Type of adhesive

•
Instrument used for prophylaxis –
 Bristle brush for 10-15 secs- abrades 10µm
 Rubber cup- abrades 5µm

 Brawn & Way- 26µm loss as a result of prophylaxis

•
Type of adhesive-
 Filled resin – clean up with rotary instruments
enamel loss- 10-25µm
 Unfilled resin – clean up hand instruments
enamel loss- 5-8µm
•
Pus & Way- high speed bur & green rubber wheel removes 20µm & low speed tungstun
carbide bur- 10µm

Van Waes et al- average enamel loss of 7.4µm with tungstun carbide bur

• Enamel Tearouts-
 Brobakken & Zachrisson- suggested that enamel tearouts are localized
& are seen specially with filled resins
-Comparison between macro(10-30µm) & micro(0.20-0.30)
- Size of hole after etching of prism core is 3-5µm so small filler
particles penetrates etched enamel
- During debonding – small fillers reinforce adhesive tags
 Macrofillers forms natural breakpoint at enamel-adhesive
interface
 Unfilled resins- no breakpoint
 Ceramic brackets- chemical retention – more damage
•
Clinical implications -
 To use brackets that have mechanical retention
 Avoid scraping of adhesive remnants with hand instruments

• Enamel cracks-
- They are Split lines which are often overlooked
- Fiber optic transillumination is used to view them
- Sharp sound on debonding – creation of crack
•
Zachrisson et al –Studied 3000 teeth in 135 adolescents
using fiberoptic light occurrence of cracks in debonded,
debanded & untreated teeth

Findings are-
 Vertical cracks common- >50%
 Few oblique & horizontal cracks
 No significant difference in 3 groups in relation to prevalence & relation of cracks
 Most notable cracks – maxillary centrals & canine
•
Clinical implications -
 Several distinct cracks after debonding on maxillary centrals & canines
 Cracks in horizontal direction- debonding techniques needs improvement
 Pretreatment examination of cracks if pronounced cracks are present.

• Adhesive remnant wear-

 Remain undetected due to colour
 Abrasion depends on – size, type & amount of reinforced filler
 Small size- abrade easily
•
Study by Brabakken & Zachrisson-
 Degree of abrasion was minimal
 Diacrylate with macrofiller & other resin with submicrometer sized particles
 Debonding – adhesive was left purposely & abrasion over 12 months was studied
 Very thin film of residual adhesive showed reduction.
•
Study by Gwinnet & Ceen-
 Unfilled sealant begin to wear & did not showed plaque accumalation
 Filled- did not wear

• Adhesive Remnant Index-

Given by Artun & Bergland
1. All composite remains on tooth surface along with impression of bracket
2. > 90% on tooth surface
3. <10% but >90% on tooth surface
4. <10% on tooth surface
5. no composite on tooth surface
 • White spot/Reversal of decalcification -
 Areas of demineralization of varying extent
 Gorelick et al – in multibanded technique 50%
developed increase in white spots
Highest incidence- maxillary laterals
• Prevention -
 Daily rinsing with dil.0.05% NaF & regular use of F
dentifrice
 Apply f varnish/ titanium tetrafluoride agent in caries susceptible areas

Hollender & Koch – reversal of white spot on labial surface after daily tooth brushing
with 0.22% NaF paste
Fehr et al – reversal of white spot along gingival margins after rinsing with 0.2% NaF for
2-4 mins
•
Recommendations –
 Daily/ twice daily application of weak (0.05%) F solution for several months
 Good oral hygiene
 If strong solution is used then it causes precipitation of ca phosphate which blocks
pores & limits remineralization.

• Microabrasion -
 Removes superficial opacities
 Eliminate enamel stains with minimal enamel loss
Procedure-
 Abrasive gel – 18% Hcl, fine powdered pumice & glycerin
 Isolate gingiva with rubber dam/block out resin
 Apply gel with electric toothbrush for 3-5mins ( smaller tip)
 Rinse for 1 min
 Can be repeated monthly 2-3 times
 Removes- white spots, streaks, brown-yellow discoloration

ELECTROTHERMAL BONDING-

- Given by Voster in 1979

- Acceleration of the setting by selective application of heat to brackets
• Heat - resistance of orthodontic bracket to a low voltage
direct current
 • of electricity passed through it by means of a specially designed
tweezer.
 Based on Arrehenius equation-
For every 18-28ºF rise in temp, speed of chemical reaction doubles & vice versa

 Temp at bracket –tooth interface is 45.9-50.2ºC at 5 amps or 84.3-98.5ºC at 7.5 amps.

 Pulp- 2-3 & 5-6ºC

Advantages –
1. Several attachments can be done with one mix composite.
2. Setting can be accurately controlled.
3. Bracket may be accurately positioned.
4. Bond achieved is strong due to less disturbance during polymerization.
5. No pulpal reaction
6. Clinician can control current level, duration of current flow & no of pulses
7. Can be used with both light & chemically cured
8. Setting occurs in 3-6secs

Influence on enamel by different debonding techniques

Enamel Surface Index - Zachrisson and Artun (1979-AJO

0 – Perfect surface - none

1 – Satisfactory – TC burs – 25,000rpm
2 – Acceptable – fine sandpaper
3 – Imperfect – medium sandpaper
4 - Unacceptable - diamond

Amount of enamel lost in debonding

The amt is related to several factors-
An initial prophylaxis with bristle brush for 10-15 sec abrade as much as 10µ.
Whereas, with rubber cups only 5µ.
Cleanup of unfilled resin with hand only results in a loss of 5-8µ.
• Removal of filled resin requires rotary inst, loss may then be 10-25µ.
• High speed bur and green rubber wheel removes appro. 20µ.
• But with careful use of TC bur,enamel loss was only 7.5µ.

Adhesive remnant index (ARI)

-Artun
• Used to evaluate the amount of adhesive left on the tooth after debonding.
Score 0 : No adhesive left on the tooth
Score 1 : Less than half of the adhesive left
Score 2 : More than half of the adhesive left
Score 3 : All adhesive left on the tooth, with
distinct impression of the bracket mesh
 CRYSTAL BONDING SYSTEM OR CRYSTAL GROWTH INTERLOKING
SYSTEM-
According Kartz & Smith, a new method of bonding that involves crystal growth on
enamel surface described. This system consists of a polyacrylic acid treatment liquid
containing a sulfate component that reacts with needle shaped crystals. These crystals
grow in spherulite manner. The crystals building on enamel surface serves as an
additional retentive mechanism for resin that bonds the orthodontic attachment to teeth.
In this extensive procedure the bond does not rely on extensive penetration into enamel &
micromechanical interlocking is created at enamel surface.
Using this method-
1. There is minimal effect on outer fluoride rich enamel layer.
2. Enamel surface is not significantly damaged.
3. Few, if any resin tags are left behind.
4. Adequate bond strength for clinical practice is achieved.
5. Debonding & clean up are much easier with minimal iatrogenic damage.
6. Crystal interface offers possibility of incorporation of fluoride or other antiplaque
agents in future to anticariogenic Action.

M.L.Jones & K.A.Pizarro BJO 1994

Conducted a study using 4 crystal growing solutions
 50% polyacrylic acid + conc.sulphuric acid
Polyacrylic Sulphates Sulphates of Sulphates of
acid • of Lithium potassium Magnesium

 Solution applied- calcium sulphate dihydrate

 Pot. Sulphate crystals were longest
 Lithium sulphate – highest shear bond strength- 80%
•
Advantages-
1. There is minimal effect on outer fluoride rich enamel layer.
2. Enamel surface is not significantly damaged.
3. Few, if any resin tags are left behind.
4. Adequate bond strength for clinical practice is achieved.
5. Debonding & clean up are much easier with minimal iatrogenic damage.
6.Crystal interface offers possibility of incorporation of fluoride or other antiplaque
agents in future to anticariogenic action.
 • ADHESION PROMOTERS-
George Newmann et al AJO 1995
Various adhesion promoters are-
1. Sandblasting -90µm aluminum oxide
2. Sandblasting + silane (Bondpor)
3. Rocatec- sandblast with 110µm of corundum, glass layer deposited on bracket base,
silane coupler
4. Silicoat- sandblast with 250µm of corundum, 0.1µm
coating of flexible ceramic.Treat with silane coupler,
opaque layer cured
•

5. Megabond Bowens promoter- 3 parts

 M1- NTG-GMA - Magnesium salt of N- Tolyglycine- glycidyl methacrylate in
acetone.
 M2- PMGDM – pyromellitic glycerol dimethacrylate in acetone.
 M3 – Mono & difunctional monomers & oligomers & activators in acetone
•
Procedure-
- Etch tooth surface & air dry
- 2 drops of M1 & M2 are mixed for 5secs & 3 coats are applied on tooth surface – glossy
- 2/3 drops of M2 & M3 are mixed & 2 coats are applied on metal mesh
- Bond bracket & allow to dry for 5secs

Indications-
 Hypocalcified teeth
 Fluorotic teeth

 Bond strength- 9-13.3 MPa

• SMARTBOND-
- In 1991- ethyl cyanoacrylate introduced
- Higher tensile strength than composites
- Used as superglue- automobiles, light aircrafts
- In medicine- fracture fixation, GTR, cardiac surgery, skin sutures
- Smartbond – ethyl cyanoacrylate + silica gel

 Polymerization starts in moisture & pressure

 If used on polycarbonate brackets- pretreated with water
 When it polymerize in presence of water white acrylic like
Powder is formed & process is called as ‘Blooming’
 Surface should be bonded closely, If not results in formation of voids
 Brackets with deep mesh/undercuts- decreased bond strength
 No residual monomer reacts later- no water absorption- no discoloration
•
Advantages-
 Bonds to wet surface
 Moisture control
 Use with metal, plastic & ceramic brackets
 Bonds to composite & porcelain materials

•
• FIBER-REINFORCED COMPOSITES (FRC)
 Fiber-reinforced composites are sometimes referred to as ‗polymers‘.
 Composed of long chain-like molecules consisting of many simple repeating units.
 Manmade polymers are generally called ‗synthetic resins‘ or simply ‗resins‘.
•
Classification - according to the effect of heat on their properties.
1.Thermoplastics - soften with heating and eventually melt, hardening again with
cooling.
 Eg-nylon, polypropylene
 Can be reinforced with short, chopped fibers such as glass
•
2. Thermosetting materials, or ‗thermosets‘, are formed from a chemical reaction
 Undergo a non-reversible chemical reaction to form a hard, infusible product.
 Eg - phenolic resins,polyester and epoxy
 Once cured, thermosets will not become liquid again if heated
•
Most polyester resins are viscous, pale coloured liquids consisting of a solution of
polyester in a monomer, which is usually styrene.
Styrene -50% -reduces viscosity
Cross-linking the molecular chains of the polyester,without the evolution of any by-
products.

 These resins can therefore be moulded without the use of pressure and are called
‗contact‘ or ‗low pressure‘ resins.
 Polyester resins have a limited storage life as they will set or ‗gel‘ on their own over
a long period of time.
•
Advantages -
 Non-corrosiveness
 Translucency
 Good bonding properties
 Ease of repair
 Potential for chair side and laboratory fabrication
•
 Long FRC – bars which joins teeth to form anchorage/ active splints
 New partially polymerized continous long chain FRC - PRE-PEGS
 Superior properties with good coupling, easily formed, flexible
Uses –
 Retention
 Anchorage
 Active tooth movement

• RIBBOND -
 Reinforced polyethylene fiber – Ribbond
 Ultrahigh molecular weight
 Treated with cold gas plasma to enhance adhesion to synthetic restorative materials
 Special fiber network- efficient transfer of stresses
 Translucent –excellent aesthetic
 Ease of adaptation to dental contours
 Ease of bonding
 Easy & fast technique – one appointment
 Acceptable strength
 Good clinical longetivity
 Thin – volume of appliance reduced
 Easy repair
•
Uses-
 Periodontal splints
 Endodontic Posts & cores
 Treat cracked tooth syndrome
 FPD
 Trauma stablization
•
1. Fixed retention-
 Etching with 36% phosphoric acid for 30 secs
 Ribbond of required size is cut & saturated with bonding agent
 Flowable composite applied on tooth surface & Ribbond
placed
•

2. fixed space maintainer

 Dentin primer applied on tooth surface
 Ribbond segment saturated & bonded with flowable composite

•
3. Temporary esthetic appliance-

4. Post traumatic stabilization splint

FRC in Lingual Orthodontics-

Anchorage reinforcement-
 2 FRC bars – labial surface from I PM to I M
 Procedure -
 Buccal surface microetched then acid etched
 Bonding agent applied over tooth surface & cured
•
 Thin layer of flowable composite applied on enamel surface & FRC positioned &
pressed against composite.
 Light cure for 5 secs
 Each fiber layer covered with layer of flowable composite & Light cure for 40 secs

• SPLINT -
 Kelvin fibers- weak in compression
 S-glass fibers – SPLINT
 Matrix- light curable thermoset BisGMA
 Modulus of elasticity – 70% greater
 Yield strength- 6 times greater
 Resilience- 24 times greater

•
1. Any attachments like brackets, hooks can be directly
bonded to FRC
 FRC bar can be easily removed by peeling action
•
•
2. Intermaxillary elastics are applied without bands/wires eliminating bracket-wire play
•
•
•
•

•
•
3. Vertical elastics to close open bite when incisor extrusion indicated
•

4. Posterior & anterior anchor units with bonded attachments

for space closure
•

5. - T- loop used for space closure with bonded ceramic bracket on anterior FRC
- Chain elastics for space closure
•

6. Uprighting second molar with full arch FRC-

 With straight archwire segment
 With T-loop

•
 Repair of FRC bars – bond replacement connector

• Bonding to Fluorosed Enamel-

- Frequent bracket failure at compromised enamel interface in fluorosed teeth due to
outer hypermineralized & acid resistant layer which prevents proper etching of enamel.
- Fluorosed enamel manifests as defects in subsurface enamel ranges from white to
brown, pits & irregular opaque lines, striations & cloudy areas
- It is seen tnat 37% phosphoric acid- decreased irregularty
Ways to increases retention are-
1. Microabrasion along with sandblasting – improves retention- aluminum oxide/silicon
carbide
2. Adhesion promoter- James Noble et al Angle Orthod 2008
 Primer- aq soln of HEMA & polyalkenoic acid- resin layer to flow on etched surface

•
 Adhesive- BisGMA & HEMA resin combined with amines
 Scotchbond multipurpose plus primer- apply & gently air dry for 5 secs
 Light cure
 Only 1 bond failure in 9 months
3. Etching time – study by Peter Ng‘ang‘a et al
 40% phosphoric acid for 60 secs- better etching pattern
 Bond strength- 7.8N/mm2 for fluorotic teeth
8.6N/mm2 for nonfluorotic
teeth

 Scotchbond MP (Multi-Purpose) - can bond to amalgam or porcelain that has been

microetched with 40-micron aluminum oxide before acid etching.
 Filled composite Concise to visible-light-cured composites for bonding, because
fluorosed enamel seems to diffract visible light and prevent complete curing
•
 1. Microetch each fluorosed tooth
 2. Etch for 20 seconds with 37% phosphoric acid gel
 3. Apply Scotchbond MP, and light-cure it for 10 seconds per tooth
 4. Apply Concise to each bracket, then position the bracket on the tooth

•
 Light cured composite veneers for fluorosed teeth. JCO 2006
 Gp A – surface cleaned with plain non-fluoridated pumice & water
 Gp B- Above+ remove 1-2mm of enamel with carbide drill
 Gp C- Above + porcelain veneers
 Bond failure- A- 74%
B- 25.9%
C- 1.7%

VARIOUS STUDIES -
Direct bonding to porcelain AJO 1995
Study done by Vanessa Barbosa, Marco Almedia, Orlando Chevitarese
 Hydrofluoric acid – better retention to porcelain
 Mucosal contact- erythema, burning with loss of tissue, intense pain for several days
 APF- other alternate

•
Bond strength between composites & RMGI as a adhesive AJO 2004
Study done by Andrew Summer et al.
 RMGI- Fuji ortho LL & composite- concise
Results-
 Decreased shear bond strength with RMGI
 Predominant failure at enamel adhesive interface
 Weak bond- easy clean up
 SEM – less rough & porous surface after 10% polyacrylic acid etching

Effect of blood contamination on shear bond strength of conventional &

hydrophillic primer AJO 2004
Study done by Marier F. Sfondrini et al
 Conventional primer- Transbond XT
 Hydrophillic primer - Transbond MIP
Results-
 Non-contaminated surface- highest bond strength
 Contaminated surface- greater but not clinically significant strength
•

Bond strength with self etching Primer AJO 2004

Study done by Helen Grubisa.
 SEP‘s – ph of 1
 Shear bond strength is less than achieved with 37% phosphoric acid
•

Bond strength of light cured GI & chemically cured GI AJO 1992

Study done by Anne M. Compton et al.
 Light cured - 80% of strength in 20 secs
 Chemically cured- 80% of strength in15 mins
 Light cured – Zionomer- 2 paste
 Chemically cured- Ketac bond ( rapid setting)
 Light curing – Ortholux for 20 secs
Results-
 Mean bond strength of light cured GI > chemically cured at 1 hr & 24 hrs
 Bond strength for both increased from 1 to 24 hrs.
•
Shear bond strength of 4 primer systems AJO 1992
Study done by Mark Neil Corril et al
 Segasealant
 Max cure
 Scotchbond 2
 Concise enamel bond
• Results-
 Shear bond strength tested with Instron testing machine
 Max cure – highest mean bond strength of 25.33N/mm2
 Scotchbond 2 – lowest
•
Bond strength of 3 GI cements AJO 1990
Study by Valerier Bowser Fajen et al
 Ketac cem , Fuji I, Precise
Results-
 Mean force for bond failure in-
Precise- 2.43pounds
Fuji I – 6.87
 Ketac cem – 11.3
 Keatc cem- highest bond strength of 3.91MPA
 It is a water hardened soln with polyacrylic acid
 Freeze dried
 Provides more consistent mix
 Minimal material between bracket & tooth- better adhesion
•
Clinical evaluation of Glass polyalkenoate cement for direct bonding AJO
1992
Study done by John Fricker
 Fuji I & system 1+
 Bracket failure recorded at 3 month intervals
Results-
 After 12 months- 12 failure with GIC & 3 with composite
 Majority failure in 6 months
 Bond strength for GI – 32kg/mm2
 Bond strength for composite– 103kg/mm2
 F release in GIC – prevents demineralizaion

 Povie et al- pretreat with polyacrylic acid to increase bond strength

 Cook & Youngston- no difference
 •
Shear bond strength of s.steel & ceramic brackets with chemically & light cured
composites AJO 1990
Study done by V.P. Joseph, Rossouw.
 Chemical- Concise ( macrofilled)
 Light – Heliosit (microfilled)
Results-
 Most fractures with chemically cured & ceramic brackets
 Creamic- high bond strength than s.steel
 Ceramic bracket fracture- 6.66%
•
Effect of phosphoric acid concentration & etch duration on enemel depth of etch
AJO 1990
Study done by L.R. Legler, D.H. Retiet, E.L. Bradley.
9 subgroups-
 37%- for 60,30,15 secs
 15% - for 60,30,15 secs
 5% - for 60,30,15 secs
• Results-
Max depth etch- 27.1µm- 37% for 60 secs
Min depth etch- 3.5µm- 5% for 15 secs
Amount of enamel dissolved increases with increase in acid conc upto 27%.
Above 27% it decreases – formation of MCPM
•
Effect of phosphoric acid concentration on shear bond strength AJO 1995
Study done by Wasundhara Bhad, Pushpa Hazarey
 5 & 37% phosphoric acid
 5% - minimal enamel loss than 37%
 No difference in shear bond strength
 Even 5% can be used

•
Effect of phosphoric acid concentration on shear bond strength AJO 1995
Study done by Wolfgang Carstensen
 Phosphoric acid concentration in 37,5,2%
Results-
 Less conc- less shear bond strength & less adhesive for removal after debonding.

•
Shear bond strength of SEP to fluorosed teeth Journal of Dentistry 2005
 Thick resin tags of 3.5µm with conventional etching
 SEP - 1µm
 Better etching with conventional acid etching.

•
Debonding techniques on enamel surface AJO 1995
Study done by K. Zarrinnia, M.J.Kehoe.
Results-
 Better bracket removal with bracket removal plier
 Bulk resin removal with- 12 fluted tungstun carbide bur at 20,000 rpm
 Finish- graded, medium/fine superfine sof-lex disks at 10,000rpm with air cooling
 Final finish- rubber cup with zircate powder

•
Role of sandblasting on retention of metallic brackets with GIC BJO 1993
 Ketac cem & Right
Results-
 Sandblasting of bracket base for 3secs at 10mm distance
 Produced good micro-roughned surface
 Increased mean bond strength by 22%
 Mean survival time increased

•
Remnant amount & clean for 3 adhesives after debracketing AJO 2002
Study done by Valerie David et al.
 Transbond, Fuji Ortho LC, Advance
Results-
 Remnants from GI were heavier than composite
 Remnants of Advance- larger
 Bonded to acid etched teeth took 1-11/2 longer to clean up
•
Enamel surface after orthodontic Debonding Angle Orthod 1995
Study done by Phillip Cambell
 Tungstun carbide bur & abrasive disks
 30 fluted tungstun carbide bur most efficient with least amount of scarring
Steps-
 Bulk removal with 30 fluted tungstun carbide bur
 Enhance cups & points to remove gross scarring
 Water slurry of fine pumice to obtain smooth surface
 Final finish with brown & green cups

•
Shear bond strength of resin reinforced GIC- AJO 1999
Study done by Chun Chung, Patrick T.C., Francis K.M.
 Concise & Fuji Ortho LC (RMGI)
Results-
 Concise strongest shear bond strength
 Fuji Ortho LC- strong bond under dry condition. Site of failure between adhesive &
enamel

•
Light & chemically cured- degree of cure/ monomer leaching & cytotoxicity
AJO 2005
Study done by Christiana Gioka et al
 Chemical- Rely-a bond
 VLC- Reliance
Results-
 Degree of cure of both do not differ
 Amount of monomer leached is same
 No cytotoxic effects on PDL
•
Antimicrobial properties of an adhesive with Cetylpyridinium Chloride AJO
2006
Study done by Tahani Musallam et al.
 S.Mutans- risk of caries
 CPC – antiplaque
 Added to filled photoactivated adhesive- Transbond XT
 Conc – 0%, 2.5%, 5%, 10%
Results-
 Bacterial inhibition with CPC
 2.5% best antimicrobial without affecting DTS
 Initial more release upto 15 days, reaches plateau upto 60 days

•
Effect of Adhesion promoters on shear bond strength AJO 2006
Study done by Ascension Vincente et al.
 Orthosolo, All-Bond 2, Enhance LC
 Contains N- Tolyglycine- glycidyl methacrylate & hydrophilic resins
 Adhesives – Transbond XT, Light bond
Results-
 High bond strength – light bond+Enhance LC
 Tranbond XT – best bond strength with Orthosolo
 Lightbond left less adhesive
 None of adhesion promoters increased adhesive remaining on tooth surface
•
Shear bond strength of 3 Self etching adhesives AJO 2006
Study done by Neslihan et al.
 Adaper prompt L-Pop
 Clearfil protect bond ( F & antimicrobial)
 Transbond Plus SEP ( F)
Results-
 Clearfil protect bond- max shear bond strength
 Adaper- adequate
 None produced enamel fracture during debonding

•
In vivo- Effect of fluoridated antiplaque dentifrice on enamel demineralization
 AJO 2006
 F paste - Tandy
 F antiplaque paste – Triclosan/zinc/Pyrophosphate
 Antiplaque –superior, less demineralization

•
Assessment of long term failure of 2 SEP’s AJO 2005
Study done by Nikolaos Pandis et al.
 Transbond plus, One step
 Failure rates recorded after 14 months
Results-
 Transbond plus – 0.94%
 One step – 8.10%
 More in mandibular arch

•
Plasma curing light & Conventional halogen curing light AJO 2005
Study done by A.P. Pettermerides, M.Sheriff, A.J.Ireland.
Transbond XT,Fuji Ortho LC
Plasma arc light- 3 secs
Halogen light- 20 secs
Results-
Transbond XT- failure rate 3.41% with both lights
Fuji Ortho LC - 11.4% with halogen & 10.2% with plasma
No difference in bond failure but time can be saved with plasma light.

•
Porcelain surface treatment by laser for bracket porcelain bonding AJO 2005
Study done by Tolga Akova et al.
 20 secs superpulse CO2 laser irradiation provides adequate bond strength between
metal brackets & porcelain surface
 Silane application after laser improves bond strength
•
Nd- YAG laser for debonding ceramic brackets AJO 2005
Study done by Kotaro Hayakawa, Chiba.
 Laser – wavelength of 1060nm
Results-
 High peak power at 2J more effective for debonding
 Max temp on pulpal walls- 5.1ºc
 Polycrystalline brackets – significant decrease in bond strength than with
monocrystalline
•

Effect of Argon laser curing on shear bond strength when bonded with light cured
GIC AJO 2005
Study done by Glaucco Serra et al.
 Argon laser for 5 secs, halogen light for 40 secs.
Results-
 Bond strength – equivalent in both groups but reduces cure time by 87.5%
 Argon leaves more adhesive on tooth surface

•
Light curing time reduction with new high power halogen lamp AJO 2005
Study done by Christine B.S. et al
 Conventional halogen- long curing time
 Low priced, high power halogen light –NEW (Swiss master light)
 Cost effective solution to reduce curing time
 Recommended time- 6 secs & with caution 3 secs.
•
Effect of bleaching on shear bond strength AJO 2005
Study done by Samir Bishara et al.
 At home bleaching- opalescence bleaching agent (10% carbamide peroxide)
 In office bleaching- Zoom (25% hydrogen peroxide
 Bonded with composite adhesive
 Bleaching do not affect shear bond strength
•
Bonding impacted teeth without moisture contamination JCO 2005
Study done by Sandhya Jain
 Etch tooth surface
 Clean & dry surface by wiping enamel with alcohol swab
 Water irrigation not needed

•
New Self Etching, Light cured Bonding system JCO 2005
Study done by Alberto Armenio
 Brajen unibond - average bond strength of 22MPa
 Fluoride release
 Viscosity prevents bracket flotation
 Good resistance to discoloration
•
Modified amalgam plugger for Etchant application JCO 2005
Study done by John Baccelli
 Std amalgam plugger modified with crosshatch file
 Etchant can adhere to surface
 Carefully scraping against enamel surface removes all debris & pellicle
•
CONCLUSION-
Simplicity of bonding can be misleading . Success in bonding requires understanding of
and adherence to accepted orthodontic and preventive dentistry principles.
It has taken half a century for orthodontic bonding procedures to evolve from acrylic to
chemically cured (2-phase, then 1) to light-cured to dual-cured (chemical light) to
moisture-active
Even the device that threatens to replace conventional brackets altogether—the
aligner—relies on bonded buttons, so it appears that some form of bonding will be with
us for a while.
BIBILOGRAPHY-

1. Graber, Vanarsdall,Vig- Orthodontics- Current principles and Techniques

Elsevier Mosby publishers- 4th Edition (579-673), 2005.

2.William Proffit, Henry Fields, David Sarver- Contemporary Orthodontics

Mosby publishers- 4th Edition (376-380, 414-417) ,2007.

3.Thomas Graber,Brainerd Swain- Orthodontics Current Principles & Techniques

Mosby Jaypee publishers- (485-564),1991.

4. Graber, Vanarsdall - Orthodontics- Current principles and Techniques

Elsevier Mosby publishers- 3rd Edition
5. Kenneth Anusavice – Phillip‘s Science of Dental Materials, Saunders publishers- 11th
Edition (381-386, 399-428, 471-486), 2006.

6.William Brantley, Theodore Eliades – Orthodontic Materials- Scientific & Clinical

aspects, Thieme publishers- (107-112, 189-219), 2007.

7. Theodore Roberson, Harald Heymann, Edward Swift – Studevant‘s Art & Science of
Operative Dentistry, Mosby publishers, (177-186), 2002.

8. Anne Compton et al- Comparison of shear bond strength of a light cured glass
ionomer & chemically cured glass ionomer for use as an orthodontic bonding agent-
Am J Orthod Dentofac Orthop 1992;101:138-144.

9. Mark Neil Corril et al- Shear bond strength of 4 orthodontic bonding systems-Am J
Orthod Dentofac Orthop 1990;97:126-129.

10. Valerier Bowser Fajen et al- An in vitro evaluation of bond strength of 3 Glass
Ionomer cements- Am J Orthod Dentofac Orthop 1990;97:316-322.

11. John Fricker- A 12 month clinical evaluation of a Glass polyalkenoate cement bfor
direct bonding of Orthodontic brackets- Am J Orthod Dentofac Orthop 1992;101:381-
384.

12. L.R. Legler, D.H. Retiet, E.L. Bradley- Effects of Phosphoric acid concentration on
enamel depth of etch- An in vitro study- Am J Orthod Dentofac Orthop 1990;98:154-160.

13. V.P. Joseph, Rossouw- The shear bond strength of stainless steel & ceramic brackets
used with chemically cured & light activated composite resins- Am J Orthod Dentofac
Orthop 1990;97:121-125.

14. Samir Bishara, Timothy Trulove- Comparison of different Debonding techniques for
ceramic brackets- An in vitro study- Am J Orthod Dentofac Orthop 1990;98:145-153.
15. Ezz Azzeh, Paul Feldon – Laser debonding of ceramic brackets- A comprehensive
review- Am J Orthod Dentofac Orthop 2003;123:79-83.

16. Vanessa Barbosa, Marco Almedia, Orlando Chevitarese- Direct bonding to porcelain
Am J Orthod Dentofac Orthop 1995;107:159-164

17. Eliakim Mizrahi, Peter Cleton, Charles Landy- Tooth surface & pulp chamber
temperatures developed during electrothermal bonding- Am J Orthod Dentofac Orthop
1996;109:506-514.

18. Andrew Summer et al- Comparison of bond strength between conventional resin
adhesive & a resin modified Glass ionomer adhesive- An in vivo & in vitro study- Am J
Orthod Dentofac Orthop 2004;126:200-206

19. Marier F. Sfondrini et al - Effects of blood contamination on the shear bond strength
of conventional & hydrophilic primer- Am J Orthod Dentofac Orthop 2004;126:217-219.

20. Helen Grubisa- An evaluation & comparison of orthodontic bracket bond strength
achieved with self etching primer- Am J Orthod Dentofac Orthop 2004;126:213-219.

21. Wasundhara Bhad, Pushpa Hazarey – Scanning electron microscopic study & shear
bond strength measurement with 5% & 37% phosphoric acid- Am J Orthod Dentofac
Orthop 1995;108:410-414.

22. Wolfgang Carstensen- Effect of reduction of phosphoric acid concentration on shear

bond strength of brackets- Am J Orthod Dentofac Orthop 1995;108:274-277.

23. K. Zarrinnia, M.J.Kehoe- Effect of different Debonding techniques on the enamel

surface – An in vitro qualitative study- Am J Orthod Dentofac Orthop 1995;108:284-293.

24. M.L. Jones, K.A. Pizarro – Comparative study of the shear bond strength of four
different crystal growth solutions- British J Orthod 1994; 21:131-137.

25.Phillip Cambell – Enamel surface after orthodontic bracket Debonding- Angle Orthod
1995; 65: 103-110.

26. Chun Chung, Patrick T.C., Francis K.M.- Shear bond strength of resin reinforced
Glass ionomer cement- Am J Orthod Dentofac Orthop 1999;115:52-54.

27. Christiana Gioka et al- Light cured or chemically cured orthodontic adhesive resins?
A selerction based on the degree of cure, monomer leaching & cytotoxicity- Am J Orthod
Dentofac Orthop 2005;127:413-419.

28. Alberto Armenio- A new self etching, light cured bonding system- Journal of clinical
Orthodontics 2005;39:584-587.
29. John Baccelli- Modified Amalgam Plugger for Etchant application- Journal of
Clinical Orthodontics 2005;39:667.

30. Vittorio Acciafesta et al- Fiber-Reinforced composites in Lingual Orthodontics-

Journal of Clinical Orthodontics 2005;39:710-714.

31. Valerie David et al.- Remnant amount & Clean up for 3 adhesives after debracketing
Am J Orthod Dentofac Orthop 2002;121:291-296.

32. Ascension Vincente et al.- Effect of 3 adhesion promoters on the shear bond strength
of orthodontic brackets – In in-vitro study. Am J Orthod Dentofac Orthop 2002;121:291-
296.

33. Geoege Newmann et al- Adhesion promoters , their effect on the bond strength of
metal brackets. Am J Orthod Dentofac Orthop 1995;108:237-241.

34. Chate R.A.C.- Safer orthodontic Debonding with rubber dam. Am J Orthod Dentofac
Orthop 1993;103:171-174.

35. Wool Arthur L.- A better Debonding procedure. Am J Orthod Dentofac Orthop
1992;102:84-86.

36. Jose W.F., Gunthur K.T. Charles Burstone- Bond strength of fiber reinforced
composite bars for orthodontic attachment. Am J Orthod Dentofac Orthop 2001;120:648-
653.

37. Charles Burstone, Andrew Kuhlberg- Fiber Reinforced composites in orthodontics

Journal of Clinical Orthodontics 2000;34:271-279.

38. James Noble, Nicholas E.K. William A.W.- In vivo bonding of orthodontic brackets
to fluorosed enamel using an Adhesion Promoter. Angle Orthod 2008; 78: 357-360.

39. Thomas W.O. Ulf Ortengren- A new orthodontic bonding adhesive. Journal of
Clinical Orthodontics 2000;34:50-54.

40. Paul Takle, Prasanna Shivpuja - Pulpal response in Electrothermal Debonding. Am J

Orthod Dentofac Orthop 1995;108:623-629.

41.Dinesh Weerasinghe et al- Micro-shear bond strength and morphological analysis of a

self-etching primer adhesive system to fluorosed enamel- Jounal of Dentistry 2005; 33:
419-426.

43. Yinzhong Duan, Xuepeng Chen, Junjie W.U.- Clinical comparison of bodb failure
using different enamel preparations of severely Fluorotic Teeth. Journal of Clinical
Orthodontics 2006;40:152-154.
44. Tahani Musallam et al.– Antimicrobial properties of an orthodontic adhesive with
Cetyylpyridinium Chloride- Am J Orthod Dentofac Orthop 2006;129:245-251.

45. Sandhya Jain – Bonding impacted teeth without moisture contamination – Journal of
Clinical Orthodontics 2005;39:473.

46. Neslihan et al- Shear bond strength of Orthodontic brackets with Self-Etching
adhesives. Am J Orthod Dentofac Orthop 2006;129:547-550.

47. Nikolaos Pandis et al.- A comparative in vivo assessment of the long term failure rate
of 2 Self Etching primers. Am J Orthod Dentofac Orthop 2005;128:96-98.

48. A.P. Pettermerides, M.Sheriff, A.J.Ireland – An in vivo study to compare a plasma &
conventional haloges curing light in orthodontic bonding. Am J Orthod Dentofac Orthop
2005;128:140.

49. Tolga Akova et al.- Poecelain surface treatment by laser for bracket-porcelain
bonding. Am J Orthod Dentofac Orthop 2005; 128: 630-637.

50. Kotaro Hayakawa, Chiba- Nd:YAG laser for Debonding ceramic orthodontic
brackets. Am J Orthod Dentofac Orthop 2005;128: 638-647.

51. Glaucco Serra et al- Effect of Argon laser curing on shear bond strength of metal
brackets bonded with light cured Glass Ionomer Cement. Am J Orthod Dentofac Orthop
2005;128: 740-743.

52. Christine B.S. et al - Light curing time reduction with new high power halogen
lamp. Am J Orthod Dentofac Orthop 2005;128: 749-754.

53. Samir Bishara et al- The effect of tooth bleaching on shear bond strength of
orthodontic brackets. Am J Orthod Dentofac Orthop 2005;128: 755-760.