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original article

Six-month bracket failure rate with a flowable
composite: A split-mouth randomized controlled trial
Sindhuja Krishnan1, Saravana Pandian2, R. Rajagopal3

DOI: http://dx.doi.org/10.1590/2177-6709.22.2.069-076.oar

Introduction: The use of flowable composites as an orthodontic bonding adhesive merits great attention because of their adequate
bond strength, ease of clinical handling and reduced number of steps in bonding. Objective: The aim of this Randomized Controlled
Trial was to comparatively evaluate over a 6-month period the bond failure rate of a flowable composite (Heliosit Orthodontic, Ivoclar
Vivadent AG, Schaan) and a conventional orthodontic bonding adhesive (Transbond XT, 3M Unitek). Methods: 53 consecutive
patients (23 males and 30 females) who fulfilled the inclusion and exclusion criteria were included in the study. A total of 891 brackets
were analyzed, where 444 brackets were bonded using Heliosit Orthodontic and 447 brackets were bonded using Transbond XT.
The survival rates of brackets were estimated with the Kaplan-Meier analysis. Bracket survival distributions for bonding adhesives,
tooth location and dental arch were compared with the log-rank test. Results: The failure rates of the Transbond XT and the Heliosit
Orthodontic groups were 8.1% and 6% respectively. No significant differences in the survival rates were observed between them (p =
0.242). There was no statistically significant difference in the bond failure rates when the clinical performance of the maxillary versus
the mandibular arches and the anterior versus the posterior segments were compared. Conclusions: Both systems had clinically ac-
ceptable bond failure rates and are adequate for orthodontic bonding needs.

Keywords: Bond failure. Flowable composite. Orthodontic bonding. Bracket survival. Adhesive. Debonding rate.

Introdução: o uso de resinas compostas fluidas como agentes de cimentação em Ortodontia tem merecido grande atenção, em função
de sua adequada capacidade adesiva, facilidade de uso clínico e número reduzido de etapas de colagem. Objetivo: o objetivo deste
estudo randomizado controlado foi avaliar o índice de falhas nos 6 meses após a colagem com uma resina composta fluida (Heliosit
Orthodontic, Ivoclar Vivadent AG, Schaan), em comparação com um adesivo ortodôntico convencional (Transbond XT, 3M Unitek).
Métodos: 53 pacientes consecutivos (23 homens e 30 mulheres) que se enquadravam nos critérios de inclusão adotados foram incluídos no
presente estudo. No total, 891 braquetes foram analisados, sendo 444 colados com o Heliosit Orthodontic e 447 colados com o Transbond
XT. As taxas de sobrevivência dos braquetes foram estimadas por meio da análise de Kaplan-Meier. As distribuições das taxas de sobrevi-
vência dos braquetes em função do adesivo usado, do dente e da arcada dentária em questão foram comparadas por meio do teste de log-rank.
Resultados: os índices de falhas para os grupos Transbond XT e Heliosit Orthodontic foram, respectivamente, de 8,1% e 6%. Não foram
observadas diferenças significativas entre os grupos quanto às taxas de sobrevivência dos braquetes (p = 0,242). Também não foram observadas
diferenças estatisticamente significativas quanto aos índices de falhas quando se comparou a performance clínica nas arcadas dentárias superior
e inferior, e nos segmentos anterior e posterior da boca. Conclusões: ambos os sistemas apresentaram índices de falhas clinicamente
aceitáveis, podendo ser considerados adequados para a colagem ortodôntica.

Palavras-chave: Falha de colagem. Resina composta fluida. Colagem ortodôntica. Sobrevivência de braquete. Adesivo. Índice de falhas.

1
Postgraduation program, Department of Orthodontics and Dentofacial How to cite this article: Krishnan S, Pandian S, Rajagopal R. Six-month
Orthopaedics, Saveetha Dental College, Saveetha University, Chennai, Tamil bracket failure rate with a flowable composite: A split-mouth randomized con-
Nadu, India. trolled trial. Dental Press J Orthod. 2017 Mar-Apr;22(2):69-76.
2
Senior Lecturer, Department of Orthodontics and Dentofacial Orthopaedics, DOI: http://dx.doi.org/10.1590/2177-6709.22.2.069-072.oar
Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India.
3
Professor, Department of Orthodontics and Dentofacial Orthopaedics, Saveetha Submitted: July 19, 2016 - Revised and accepted: September 27, 2016
Dental College, Saveetha University, Chennai, Tamil Nadu, India.
Contact address: Sindhuja Krishnan
» The authors report no commercial, proprietary or financial interest in the products Department of Orthodontics and Dentofacial Orthopaedics, Madha Dental
or companies described in this article. College, MGR University, Chennai, Tamilnadu, India
E-mail: reachsindhuja@yahoo.com

© 2017 Dental Press Journal of Orthodontics 69 Dental Press J Orthod. 2017 Mar-Apr;22(2):69-76

10 Heliosit to bond brackets to etched teeth using chemical or Orthodontic was developed to ease the bonding pro- light-curing adhesive systems. was determined to be 813 brackets.3 compare the bond failure rates of brackets bonded with The majority of adhesives currently used for orth. The null hypothesis is that there is no dif- viscosity of Bis-GMA. bond strength. Ca. » Patient requiring fixed appliance therapy in both Flowable composites retain the same small particle arches.5. Institutional review attention due to their clinical handling characteristics. urethane dimethacrylate. as tooth location and methacrylate (TEGDMA) as a diluent to reduce the dental arch. contraction (dimensional changes).7 ets. © 2017 Dental Press Journal of Orthodontics 70 Dental Press J Orthod. 1) no stickiness. improved workability with increased vis.8 board clearance and approval from human ethical Flowable composites exhibit two desirable clinical han.1. 3M Unitek. committee were obtained from the Saveetha Univer- dling characteristics that have not existed for composites sity for this single-centered study and patients gave until very recently:9 their written consent for participation. the sample size microleakage. the number of brackets bonded either with Trans- forcement of matrix material. reduction in polymeriza. thus. contributing to bracket failure. Estimation of power and sample size crease the strength of the composite and reduce the The sample size of the study was estimated by amount of matrix material. Heliosit Orthodontic (Ivoclar Vivadent AG. The secondary aim was to investigate factors dimethacrylate (EGDMA) or triethylene glycol di. » Patient with congenital enamel defects. For 813 brack- cosity. It results in reduced To obtain an adequate power of 80%. shorter curing » Complete permanent dentition. sufficient working time. » Partially erupted teeth. In this study.4 months of preadjusted edgewise appliance therapy. Schaan) and a conventional multi-step system of synthetic polymers such as bisphenol-A glycol di.22(2):69-76 . » Absence of labial or buccal restoration. MATERIAL AND METHODS The primary purpose of the filler particles is to in. The fillers provide rein. The high initial bond cedure of orthodontic attachments by eliminating the strength. reduction in water sorption and softening.original article Six-month bracket failure rate with a flowable composite: A split-mouth randomized controlled trial INTRODUCTION dispersed silicon dioxide (14 wt %). tion shrinkage and reduction in thermal expansion and each bonded bracket was the unit of measurement. it’s a standard clinical practice contents are catalysts and stabilizers (1 wt %). liosit Orthodontic or Transbond XT during the first 6 action are incorporated. Inclusion criteria The other desirable characteristics include adequate » Age group: 13 to 30 years. time. highly translucent single-component Exclusion criteria bonding material for brackets and is supplied in con. sizes of traditional hybrid composites. et placement have contributed to the popularity of The purpose of this randomized clinical trial was to light-curing adhesives. USA) over a 6-month methacrylate (Bis-GMA) with either ethylene glycol period. Schaan) is a light-curing. but have less filler » Both extraction and non-extraction cases. The additional In orthodontics. reducing the viscosity of the mixture. flowable composites merit great loss of patients during follow-up. content. methacrylate (85 wt %). on etched tooth surface. (Transbond XT. and improved ease of use. bond  XT or Heliosit Orthodontic. Bis-GMA and decandiol di. Filler particles are incorporated into a resin matrix to improve its mechanical properties. mol. the minimal extent of oxygen inhibition need for primer application both on the bracket base and and the extended working time for optimal brack.2. approximately 53 patients were required. Vivadent odontic bonding are complex materials composed Ivoclar.6. The monomer matrix consists of hypoplasia. fillings or venient syringes. ference in the failure rates of brackets bonded with He- ecules that promote or modify the polymerization re. A buffer Among the composite resins that could be used as of 20% was included in order to compensate for any orthodontic adhesives. The filler consists of a highly » Second and third molars. 2) fluid injectability. 2017 Mar-Apr. a flowable composite (Heliosit Orthodontic. In addition to the above.

rinsed.85% lary and mandibular right and left quadrants. Trans.1% The adhesives were separated based on group category. 53 consecutive patients (23 males and 30 fe. and Distribution of brackets by side of the arches vice versa in Group B (Table 1). 2017 Mar-Apr. All the pa- tients were bonded with 0.15% both materials would be equally distributed on maxil. split-mouth.Sample characteristics.9% side was allocated by using a Random Number Table. the to. according to the MBT bracket positioning chart. For the teeth to be bonded using Transbond gauge. The decision as to the choice of material for each Maxillary 445 49. Distribution of brackets by tooth type In Group A. The total number of patients involved in the study was 53 (23 males and 30 females). Patients were selected from those seeking orthodontic treatment at the Orthodontics Department of Saveetha University. Bonding procedure As per the manufacturer’s recommendation no inter- It was not possible to blind the operators to the mediate primer was applied on the surface to be bond- bonding system being used because the two systems ed. sive paste was placed on the back of the brackets. Pandian S. Rajagopal R original article Table 1 . The teeth were of the brackets and the brackets were placed onto the cleaned using a rubber cup with pumice and water etched enamel surface. For 53 patients. XT. By the end of the 6-month trial. Transbond XT adhe- of bonding. The characteristics of the odontic. » Dentition with occlusal interferences. Sufficient pressure was applied to squeeze out excess adhe- el surface for 15 seconds before rinsing with water sive. Mandibular 446 50.45% bond  XT on the right side and Heliosit Orthodontic Posterior 290 32.Krishnan S. Anterior 601 67. and dried with oil. 37% phosphoric acid was applied to the study sample are described in Table 2.22(2):69-76 . isolated with cheek retractors and a In both groups the brackets were positioned along the low-volume suction evacuator. which was removed from the margins of the bracket © 2017 Dental Press Journal of Orthodontics 71 Dental Press J Orthod. 3M Unitek). the total number of brackets bonded was 901.1% side of the mouth chosen for bonding of the brack.022-in slot MBT prescrip- tion (Gemini stainless steel brackets. 37% phosphoric acid was applied to the enam. the brackets were bonded with Trans. slurry.9% Distribution of brackets by dental arches ets. This was done so that Right side 438 49. Number of patients 53 - bond XT was used as the control material and Heliosit Number of brackets 891 - Orthodontic was used as the experimental material.55% on the left side of maxillary and mandibular arches.Quadrant-wise distribution of adhesive. Distribution of brackets by bonding material The patients were unaware of the material and the Transbond XT 447 50. long axis of the teeth with the help of a bracket positioning free air. Another enamel according to the manufacturer’s instructions patient discontinued treatment after the third month and given a gentle burst of air. Two and drying until the enamel became frosty white. enamel surface for 15 seconds before rinsing with water and drying until the enamel was frosty white. patients were excluded from the study as they did not Transbond XT primer was then applied to the etched come regularly for the monthly follow-up. n % cross-arch Randomized Controlled Trial. tal number of patients analyzed was 50 and the number For the teeth to be bonded using Heliosit Orth- of brackets analyzed was 891. The study design was a single blinded. Heliosit Orthodontic 444 49. Study design Table 2 . » Surgically exposed teeth. GROUPS Right side Left side Thus. Left side 453 50. A Transbond XT Heliosit Orthodontic B Heliosit Orthodontic Transbond XT males) who fulfilled the inclusion criteria were selected for this study. Then Heliosit Orthodontic was placed on the back had different forms of application.

2017 Mar-Apr. Dentsply).43). RESULTS fied with the bracket positioning. 95% confidence about diet and care were given immediately to the pa. 95% degree of alignment and crowding. level = 0.1%) and distal aspects for 10 seconds each. and elastomeric modules.83). n= 891) (anterior and posterior) were compared using the log-rank test (p < 0.0 (SPSS Inc. Discontinued intervention (n= 0) Discontinued intervention (n= 0) butions with respect to bonding procedure. the 6-month observation period . The first and second Randomized (n= 53 patient) premolars brackets were evaluated in the posterior segment as the molars were banded. © 2017 Dental Press Journal of Orthodontics 72 Dental Press J Orthod.35-1. but TRANSBOND XT GROUP (n= 53 patient) HELIOSIT ORTHODONTIC GROUP (n= 53 patient) not included in the further study.016-in NiTi wire. If a bond failed. Patients were followed for a period ferences between anterior and posterior brackets in of 6 months.71.014-in NiTi icant difference in terms of bracket failure risk over the 6 wire or a 0.40. Based on the tooth location. the adhesive was cured The flow chart of the trial is given in Figure 1.. Bracket survival distri.22(2):69-76 .20-0.05).5%). these were treatment.original article Six-month bracket failure rate with a flowable composite: A split-mouth randomized controlled trial base with an explorer before polymerization.242. The log-rank test showed no significant dif- tor (investigator). These wires were confidence interval 0. When the patient was unaware of a bracket failure. gingival.69. 63 (7. mesial 27 (6%) in the Heliosit Orthodontic group and 36 (8. follow-up and assessment of bond shows the influence of tooth location on bracket sur- failure rate of the brackets was done by a single opera. Kaplan-Meier estimates of bracket month) month) survival curves were plotted.251). the date of Excluded (n= 0) • Not meeting inclusion criteria (n= 0) • Declined to participate (n= 0) the appointment was recorded as the date of failure. Failed brackets were rebonded with the conventional adhesive. The study was concluded before the addition not statistically significant according to the log-rank of edgewise archwires. The corresponding Standardization was achieved by bonding all the bracket survival curves were plotted by using the Kaplan- brackets in one appointment by the same operator. • Received allocated intervention (n= 53) • Received allocated intervention (n= 53) Statistical analysis Followed up for 6 months Followed up for 6 months Statistical data analysis was carried out by us- ing the software SPSS v. hazard ratio = 0. Verbal and written instructions test (P = 0. No bite planes were used during the mandibular arches a 3. Posterior brackets (premolars) showed lesser (2. they were divided into anterior and posterior segments. at the 5% level of significance. Figure 1 .36-1. The patients were treat- ed at 3-4 week intervals but were requested to come Assessed for eligibility (n= 53 patient) as soon as possible in case of a bond failure. in the Transbond XT group (Table 3). (2) number 95% confidence level = 0.8% failure rate.  4. and (4) pos- sible reason for bond failure. hazard ratio = 0. There was no signif- Aligning archwire of choice was either a 0. the following informa. tion was recorded: (1) site of bond failure. n= 48) (bonds.6%) Observation and follow-up failure rates than anterior brackets (4. Figure 4 The bonding.0492. follow-ups properly and one patient follow-ups properly and one patient discontinued treatment from the third discontinued treatment from the third plan-Meier test.1%) brackets failed: The adhesive was cured from the occlusal. log rank test P = 0. Chicago. dental arch (maxillary and mandibular) and tooth location Analyzes (patient.518. vival rate. hazard ratio = 0. The influence of the dental arches on tient after fitting the appliances. bracket survival rate is shown in Fig 3. depending on the initial months between groups (p = 0. When satis. terms of survival rate (P = 0. Meier product-limit estimate (Fig 2). n= 891) (bonds. using The maxillary arches had a 3. of failed brackets (3) date of bond failure. tied approximately 10 minutes after bonding.3% failure rate. The survival Lost to follow-up (n= 3) Lost to follow-up (n= 3) (Two patients did not report for monthly (Two patients did not report for monthly rates of the brackets were estimated by using the Ka.42.The CONSORT flow diagram of the trial. USA). n= 48) Analyzes (patient. During using a Halogen light curing unit (QHL75.

0 Segment Anterior Bis-GMA and decandiol dimethacrylate (85 wt%). 2017 Mar-Apr.17 Heliosit Orthodontic was developed to facilitate Figure 3 .0 clinically assess its bonding efficacy. The overall censored bond failure in this study was 63 brackets with 7.4 of patients.Overall Kaplan-Meier survival plot comparing bond failure between sidered clinically acceptable.0%).16 In in vivo studies. Further- 0. for 0. research designs and trial durations. Its mono- Survival Functions mer matrix consists of urethane dimethacrylate.0 0 50 100 150 200 250 various adhesive-bracket combinations.1%) and 27 (6.2% and 5. socioeconomic and dental status 0.0 Transbond XT bond failure rates between the Transbond XT and the Heliosit Orthodontic 0.8 Transbond XT censored Heliosit Orthodontic Heliosit Orthodontic groups at p < 0.11 0.0 turally influenced dietary habits.4 tion has been as an adhesive for bonding lingual retain- 0. its applica- 0. cul- 0. Additional contents are catalysts and stabi- Cumulative Survival 0.14 It is difficult to make Transbond XT (3M Unitek) and Heliosit Orthodontic (Ivoclar Vivadent).0 Arch Maxillary forward statement of the overall percentage of failures in Mandibular Maxillary-censored Mandibular-censored a sample over a certain time.6%. This could provide a straight- 1.2 Adolfsson et al12 and Cal-Neto et al13 reported failure rates of 4. It is a Bis-GMA-based light- curing orthodontic adhesive designed for bonding ceramic and metal orthodontic brackets. the overall failure rates for a clinical Survival Functions sample can be calculated.1% Cumulative Survival 0.Krishnan S. or it can be used to compare 0. and sex differences 0 50 100 Days 150 200 250 may also influence the results. Rajagopal R original article DISCUSSION Survival Functions There was no statistically significant difference in Group 1. bond strength within the already-mentioned clinically © 2017 Dental Press Journal of Orthodontics 73 Dental Press J Orthod.6 means of representing the performance of brackets. masticatory forces varying with facial type. Days Bond failure rates below 10% are generally con- Figure 2 .22(2):69-76 .9 to 7. The bond failure of Transbond XT and Heliosit Orthodontic was 36 (8.8 MPa were clinically acceptable and Heliosit Orthodontic adhesive had shear Figure 4 .29 and even as a luting cement for prosthesis.Overall Kaplan-Meier survival plot comparing bond failure in maxil- lary and mandibular arches. Although Heliosit Orthodontic was initially developed for bonding of brackets. materials. Studies by O’Brien et al.6 failure rate. Failure rates are a widely accepted Cumulative Survival 0.7-6.05.8 (14 wt%). malocclusion classification and resultant mechanotherapy may affect the outcomes. Posterior Anterior-censored Posterior-censored The filler consists of highly dispersed silicon dioxide 0. Reynolds19 stated 0 50 100 Days 150 200 250 that bond strengths of 5. 1.18 Heliosit Orthodontic has not been widely studied to 0. 7.8 variables in a sample.48%.Overall Kaplan-Meier survival plot comparing bond failure in ante- rior and posterior segments.28. orthodontic bonding by eliminating the need for primer application both on the bracket base and the etched tooth surface.15 In any time scale. a direct comparison between studies due to the vari- ety of techniques.2 ers.2 more.4 respectively (Table 3). respectively. Pandian S. 0.6 lizers (1  wt%).

survival analysis showed that the mean survival time for ing Heliosit Orthodontic with Transbond XT. studies brackets bonded with Transbond XT (178.601 .original article Six-month bracket failure rate with a flowable composite: A split-mouth randomized controlled trial Table 3 . with mandibular bonds failing more frequent- here because non-failed attachments were all censored ly (maxillary = 3.3% 0. Ca. O’Brien et al11 presented three possible reasons for bond XT. The Kaplan-Meier ried out to evaluate its bond strength. Heliosit Orthodontic can be applied to acid. the maximum number Manufacturers claim that its flexural strength is 80 MPa of bond failures occurred during the initial 3 months and that the shear bond strength of brackets on etched of treatment. Schaan. By reducing the number of steps during bonding. therefore. period. mandibular = 3. Similar results have © 2017 Dental Press Journal of Orthodontics 74 Dental Press J Orthod. failure rates demonstrated no sig- fers from other types of statistics because it can use nificant differences between maxillary and mandibular partial or censored information.20. cli. While compar.21. orthodontic appliances. This analysis dif. Thus.492 Posterior region 290 23 2. allows easier and more even application to the mesh base 2) The initial period of treatment is also a time of of the brackets.304 (Table 3).5% 0. the bond strengths Another factor observed in relation to survival time of Heliosit Orthodontic were clinically acceptable.8% at the conclusion of the treatment. This analysis was used brackets.488 . USA). in the present study. biting on a hard food substances.03 days) (Fig 2).8% Bracket location Anterior region 601 40 4.242 . a survival analysis was done. 2017 Mar-Apr. In the present study.518 Mandibular arch 446 34 3. 3) The initial phase of treatment may involve a pe- ceptable survival rate. strengths in all the studies. Few in vitro studies have been car. Unlike orthodontic bonding systems. it is undoubtedly advantageous for riod of overbite correction and.83 days) was concluded that Transbond XT exhibited higher bond similar to Heliosit Orthodontic (179. such as Trans.1% 0.Overall bracket failure rate between Heliosit Orthodontic (Ivoclar Vivadent. Variable Number Bracket failures Failure rate (%) p value log-rank Material used for bonding procedure Transbond XT 444 36 8. and it is impossible bond failure) at p = 0. However . It also treatment.6% acceptable range.22(2):69-76 . Another added advantage of using this acclimatization and experimentation for patients con- flowable composite is that it proves to be more cost ef. the increased failure rate during the first 6 months of etched enamel without the use of intermediate bonding treatment: resin due to its low filler loading and improved flowabil. to follow all the brackets to failure. strength of any individual bracket/adhesive combina- nicians can save time and reduce potential errors related tion would become evident within this initial period of to contamination during the bonding procedure.22 was that. for ceramic brackets and 12 MPa for patients for the bond failures were hard brushing and metal brackets.251 Heliosit Orthodontic 447 27 6% Dental arch Maxillary arch 445 29 3. 1) They suggested that any deficiencies in the bond ity. clusal forces may be applied to many of the bonded Since not all brackets failed by the end of the study attachments.  as Heliosit Orthodontic guarantees clinically ac.3% bond failure. heavy oc- orthodontic bracket bonding. Liechtenstein) and Transbond XT (3M Unitek. cerning the type of food that can be tolerated by fixed ficient as it does not require an intermediate primer. The most common reasons cited by the enamel is 10 MPa.

with a normal transverse arch relationship. which predispose cer- tain sites to a greater rate of bond failure. commercial. Many studies report that posterior teeth suffer more bracket failures than do brackets on anterior teeth. the findings were not statistically significant at p < 0. the conven- rate of mandibular brackets. Rajagopal R original article been obtained in other studies which found that the fail. This can be due to some factors within the oral cavity like tooth morphology.33 days. anterior = 4. The  higher occlusal forces on posterior teeth. CONCLUSIONS ure rate of maxillary brackets was less than the failure 1) In this randomized controlled trial.22 days). the difficulty of access and moisture control and the more aprismatic enamel on premolars could be pos- sible reasons for this scenario. Pandian S. whereas maxillary brackets do not.23-26 tional adhesive (Transbond XT) and the flowable com- Potential reasons for this could include increased posite (Heliosit Orthodontic) had similar and clinically masticatory load on mandibular brackets.6% bond failure and mean survival time of 178. than anterior teeth.05 (Table 3). This was true for the overall sample (posterior = 2. the choice of a particular orthodontic This research did not receive any specific grant from funding bonding adhesive will depend on the clinical preference agencies in the public.22(2):69-76 . However. Undoubtedly. duces chair time.27 The literature on bonding has shown that the pat- tern of orthodontic bond failure in vivo is not uniform for all the teeth in either dental arch and also between the arches. From a clinical standpoint. © 2017 Dental Press Journal of Orthodontics 75 Dental Press J Orthod. mastica- tory forces and chewing pattern.Krishnan S. thus. This occurs even though all the teeth are bonded by the same operator using the same adhesive and a standard protocol. Present results indicate that both Transbond XT and Heliosit Orthodontic can be efficiently used for bond- ing orthodontic appliances. saves chair time. or not-for-profit sectors. thus emphasizing that only cer- tain sites in the mouth have a greater predilection for failures than others. In patients acceptable bond failure rates. brackets 2) Heliosit Orthodontic is a more desirable compos- bonded to mandibular teeth have potential antagonists ite because it reduces the number of clinical steps. 2017 Mar-Apr. It is also cost effective. it improves the quality of bonding and efficiency of the operator by reducing the risk of salivary contamination during the bonding procedure. the use of Heliosit Orthodontic can be more advanta- geous because it reduces the number of clinical steps re- quired to bond brackets and. Formatting of funding sources However. of the operator. A disadvantage to this technique of using flowable composites as orthodontic bonding adhesive is that it denies application of a filled sealant that protects the enamel from white spot lesions.11. is cost effective and reduces the risk of It is evident that posterior teeth failed less frequently salivary contamination. It re- in centric relation.5% bond failure and mean survival time of 179.

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