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SPECIAL ARTICLE

Efficient and effective indirect bonding

Anoop Sondhi, DDS, MS*


Indianapolis, Ind

A new resin designed specifically for indirect bonding has been developed. Previous problems with indirect
bonding systems, which were partly related to the fact that resins designed for direct bonding had to be
used, have been addressed. A cohesive and complete system for fabricating bonding trays, and the indirect
bonding procedure, is presented. (Am J Orthod Dentofacial Orthop 1999;115:352-9)

It has been widely recognized for many high. Different glues have been tried over the years, but
years that accurate bracket positioning is of critical only with moderate success.
importance in the efficient application of biomechanics Heat-cured resins subsequently entered the market,
and in realizing the full potential of a preadjusted edge- but several clinicians have experienced problems with
wise appliance. The same principle that governs real bracket float while heating the resin. This is aggravated by
estate is applicable to bracket positioning—Location! the fact that the model must be heated to 350° for approx-
Location!! Location!!! imately one half hour to cure the resin (Thermacure,
Reliance Orthodontic Products). Further, ceramic brack-
BRACKET POSITIONING AND DIRECT BONDING ets could not be exposed to such heat and had to be placed
The advent of direct bonding improved the clini- separately after the metal brackets had been heat cured, a
cian’s ability to position the brackets more accurately cumbersome procedure. Current techniques for bonding
than when using bands. The introduction of light-cured tray placement use chemically cured sealants or bonding
resins like Transbond XT Light Cure Adhesive (Trans- resins. However, if a transparent tray is used, light-cured
bond, 3M/Unitek, Monrovia, Calif) further improved resin, with cure-on-demand benefits, can be used.7
the working time available to the clinician, permitting
significant latitude in positioning the brackets before the RESIN DESIGN
resin is cured. However, achieving an accurate and con- This clinician has consistently used indirect bond-
sistent bracket position on the posterior teeth continues ing in one form or another for the last 16 years. It
to present a problem because of poor access. Rebonding became clear that one of the deficiencies in the avail-
on posterior teeth isn’t any easier than bonding them the able systems is that all the resins and procedures had
first time, therefore the less bracket repositioning one originally been designed for direct bonding, and subse-
has to do on the posterior teeth, the better. On the ante- quently were just adapted for indirect bonding.
rior teeth and the premolars, the cost of repositioning For example, a desirable feature for a resin
the increasingly popular ceramic brackets is of concern. designed for direct bonding is a generous window of
This is less of an issue with indirect bonding. working time. In indirect bonding, once the tray is
placed there is clearly no use for an extended cure time.
BRACKET POSITIONING AND INDIRECT BONDING After years of innovation, laboratory testing, and clini-
Indirect bonding, in various forms, has been around cal trials, a significantly superior, efficient, and effec-
for several years.1-6 Most of these forms have been tive indirect bonding procedure has been developed
variations on the technique originally proposed by utilizing a new resin specifically designed for indirect
Thomas.1 Initially, we used candy to position the bonding. An additional benefit of this procedure is that
brackets on the teeth, and chemically cured resins to it does not require heating the models, since a custom
bond the brackets to the teeth. This generally resulted base is developed with light-cured adhesive.
in excessive flash, and clean-up was a significant prob-
lem. In addition, the laboratory time was excessively ADVANTAGES OF INDIRECT BONDING
Obviously, there are some significant advantages to
*Research is supported in part by 3M/Unitek. indirect bonding1-7:
In private practice. 1. Accurate bracket placement
Reprint requests to: Anoop Sondhi, DDS, MS, 9333 N Meridian, Suite 301, 2. Optimizing the use of doctor’s time
Indianapolis, IN 46260
Copyright © 1999 by the American Association of Orthodontists. 3. Avoiding band fitting on posterior teeth
0889-5406/99/$8.00 + 0 8/1/97643 4. Eliminating the need for separators
352
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 353
Volume 115, Number 4

A
A

B
B

C
Fig 1. Anterior (A) and occlusal (B) views of maxillary C
working models for indirect bonding. C, application of
separating medium. Fig 2. A, Placement of APC brackets on the working
model; B, lateral view of working model shows individual
bracket positions; C, models ready to be checked; mod-
els are kept in a black box to keep out ambient light.
5. Improved ability to bond posterior teeth
6. Improved patient comfort and hygiene
new resin has been developed with the help of 3M
DISADVANTAGES OF INDIRECT BONDING Unitek. This material is designed with several objectives
1. Technique sensitive in mind. The viscosity has been increased with the use of
2. Additional set of impressions needed a fine particle fumed silica filler (approximately 5%), so
3. Posterior attachments more likely to fail if that any small imperfections in the custom base crafted
patient chews ice, etc. from the light-cured adhesive, as well as any imperfec-
tions in the fit of the custom base against the enamel, will
A NEW INDIRECT BONDING MATERIAL be taken up by the filled resin. An unfilled resin, on the
Having recognized the clinician’s need for bonding other hand, would be less viscous and could cause
materials designed specifically for indirect bonding, a bracket drift. Further, the resin has a quick set time of 30
354 Sondhi American Journal of Orthodontics and Dentofacial Orthopedics
April 1999

A
Fig 3. Maxillary and mandibular indirect bonding mod-
els placed in the TRIAD chamber.

seconds, which significantly decreases the time needed to


hold the bonding tray. The resin is completely cured in 2
minutes, allowing relatively rapid removal of the bonding
tray. This resin has been specifically designed for indirect
bonding and would not be useful for direct bonding.

CUSTOM BASE WITH LIGHT-CURED ADHESIVE


B
After a number of clinical trials, it was determined
that preparing a custom resin base with a light-cured
resin is quick, efficient, and easy. Using APC brackets,
contamination is eliminated and laboratory time is cut
to a minimum because individual brackets do not need
to be sorted or have resin applied to the base before
placing on the model. If APC brackets are not used,
then we recommend Transbond XT as the material of
choice for preparing the resin bases.
For the indirect bonding procedure, this clinician
now uses the new indirect resin, with APC brackets (or
Transbond XT adhesive applied in the lab) for the cus-
tom base. The following is a step by step explanation of C
the indirect bonding procedure.
Fig 4. A, Prewelded hooks of brackets blocked out with
PREPARATION OF BONDING TRAYS Mor-Tight; B, models placed on Biostar machine for
vacu-forming of tray; C, model with first layer of Bioplast
1. Working models in orthodontic stone, prepared
positioned for placement of the hard Biocryl.
from accurate alginate impressions, are neces-
sary. Care should be taken to ensure that there
is no distortion of the impressions. The work- used, the preoriented brackets may be removed
ing models should be prepared with careful directly from the sealed blister and positioned on
trimming, removal of bubbles, and filling of the individual teeth. The excess adhesive should
small voids. If there are large bubbles or voids, be removed, and the position of the bracket care-
it will affect the fit of the bonding tray (Fig 1A fully checked with a bracket gauge. If noncoated
and B). brackets are used, then Transbond XT Light Cure
2. A thin layer of Al-Cote (Dentsply International, Adhesive should be placed on the mesh pad of
Inc, York, Pa) separating medium should be individual brackets before they are positioned on
applied to the models and allowed to dry for the model (Fig 2A).
approximately 1 hour (Fig 1C). 4. Once all brackets have been placed, any excess
3. If APC (3M/Unitek) Adhesive Coated brackets are should be removed. The models should be placed
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 355
Volume 115, Number 4

A D

E
Fig 5. A, Sectioned tray being removed from model; B,
trimmed indirect bonding trays placed in the TRIAD
B chamber for additional curing; C, occlusal view of indi-
rect bonding tray; D, tissue-side view of indirect bonding
tray clearly identifying inner soft layer and outer hard
shell; E, close view of individualized bonding pads
formed with Transbond.

(TP Orthodontics, LaPorte, Ind) or wax. Alterna-


tively, these areas may be trimmed off the bond-
ing tray to permit easier removal (Fig 4A)
7. The indirect bonding trays can now be placed
over the brackets. We use a Biostar (Great Lakes
Orthodontics, Tonowanda, NY) unit to vacu-form
C a 1 mm thick layer of Bioplast (Great Lakes
Orthodontics), overlayered with a 1 mm thick
layer of Biocryl (Great Lakes Orthodontics). The
in a black plastic box and left for final approval bonding tray’s hard outer shell should be trimmed
and positioning by the doctor (Fig 2B and C). away from all heights of contour for patient com-
5. Once all the bracket positions have been checked, fort and closer fit because it only permits firm
the upper and lower models should be placed in seating of the soft tray (Fig 4B and C).
the TRIAD (TRIAD 2000, Dentsply Interna- 8. If a Biostar unit is not available, a bonding tray
tional, Inc) curing unit and cured for 10 minutes. can also be made with a suitable silicone transfer
Although the resin will actually cure much more material. Once the putty has been mixed with the
quickly, extra time is allowed to ensure complete activating agent, a small button of the silicone
curing because the access to light between the material can be placed around individual brack-
plaster model and the bracket base is limited. This ets, followed by the placement of the remaining
is not as much of a concern with Clarity Ceramic material rolled into the shape of a cylinder. The
Brackets (3M/Unitek) (Fig 3). occlusal and lingual surfaces of the teeth should
6. Before forming the indirect bonding trays, it is also be covered with the tray material.
recommended that significant undercut areas, 9. The bonding trays are now removed from the
such as hooks, be blocked out with Mor-Tight models and may have to be sectioned off with a
356 Sondhi American Journal of Orthodontics and Dentofacial Orthopedics
April 1999

A A

B B
Fig 6. A, Isolation of working area with NOLA dry-field
system; B, etched enamel surface being air dried.

bur. It may be necessary to tease the tray off with


a scaler. Any excess material should be trimmed
with crown and bridge scissors or a scalpel. Once
the bonding trays have been trimmed, they
should be placed in the TRIAD unit for an addi-
tional minute to ensure that any uncured resin is
cured (Fig 5A and B).
10. The trays should now be cleaned in an ultrasonic C
cleaner with a dishwashing detergent (eg, Dawn,
Fig 7. A, Indirect bonding resin being poured into wells;
Proctor & Gamble) for 5 minutes. The trays are
B, resin A being applied to tooth; C, resin B being
then run through the ultrasonic, in water only, for applied to bracket base.
an additional 5 minutes. They are then rinsed and
dried thoroughly. Fig 5C, D, and E show views
of the finished bonding trays and a close-up view
of the custom resin bases that have been formed 2. Pumice all teeth. Explain to the patient that this is one
on the brackets. of several procedures in preparation for bonding.
3. Rinse and suction well with water.
INDIRECT BONDING PROCEDURE 4. Show the bonding trays to the patient and explain
Initial Preparation the procedure—from taking the impressions to
1. Seat patient and place a napkin around the neck. We placing the brackets in the proper position and
recommend the use of Sal-Tropine (Hope Pharme- forming the tray. It is important to stress the time
ceuticals, Scottsdale, Ariz) as an antisialagogue. the doctor spends positioning the brackets and
The patient should be instructed to remove any con- supervising the entire process. We believe there
tact lenses when they take the Sal-Tropine tablet. is a significant value in emphasizing the value of
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 357
Volume 115, Number 4

A A

B B

C C
Fig 8. A, Placement of mandibular bonding tray; B, max-
illary and mandibular bonding trays in place; C, removal
of mandibular bonding tray.

proper bracket placement and the doctor’s input


on appliance design to the patient.
5. If there are bands to fit, this should be completed
after the indirect bonding procedure has been
completed. Because this indirect bonding resin
has such a fast set time, the band fitting can be
started immediately. D
Patient Bonding
Fig 9. Indirect bonded appliance: A, anterior view; B, lat-
1. Whether the indirect bonding procedure can be eral view; C, maxillary occlusal view; D, mandibular
completed with a single tray for the entire arch or occlusal view.
358 Sondhi American Journal of Orthodontics and Dentofacial Orthopedics
April 1999

need to be mixed), the degree of isolation and


ease of tray placement are the determining fac-
tors. On rare occasions, it may be advisable to
consider sectioning the tray into thirds, in which
case the trays may be sectioned as follows:
6-11 or 27-22 (anterior segment)
2-5 or 12-15: 31-28 or 21-18 (posterior segment)
2. Examine the trays carefully for any remaining sep-
arator or tray material covering the adhesive cus-
tom base on the bracket. Use a micro-etching unit
to lightly sandblast the adhesive custom bases. A
A fine aluminum oxide particle (50 µm) is recom-
mended. Take care not to abrade the resin base.
3. If there is any contamination of the adhesive cus-
tom bases, especially if you touch them with
your fingertips, apply acetone to adhesive bases
and air dry them.
4. Isolate the teeth that are to be bonded with the
NOLA (Nola Specialties, Hilton Head, SC) dry-
field system. Occasionally, if necessary, plastic
cheek retractors, Tongue Away (TP Orthodon-
tics), cotton rolls, and Dri-Angles (Young Dental,
Earth City, Mo) may be used (Fig 6A).
5. Using air syringe, dry teeth thoroughly.
B 6. Dab—do not rub—etching solution onto teeth
and set stop-watch for 30 seconds. (Note: Etch-
ing solution should be applied with extreme
care. Do not allow etch to contact skin or gin-
giva.) The etch should be applied in the general
area that is to be covered by the bracket. Do not
allow the etch to flow into the interproximal con-
tacts. The clean up will go much more smoothly
if this is kept in mind.
7. After 30 seconds, rinse with a steady stream of
water for 15 seconds. Rinse with a steady spray
of water and air for another 30 seconds. Suction
C excess water and be careful that saliva does not
come into contact with the etched enamel.
Fig 10. Bar graph shows (A) bond strength 24 hours 8. Replace cotton rolls and Dri-Angles, again making
after bracket placement; indirect adhesive compares
sure that saliva does not contact the etched enamel.
favorably with Concise and Transbond; B, bond strength
9. A. If the clinician chooses to use Transbond MIP
5 minutes after bracket placement; these data are of crit-
ical importance because the immediate bond strength is Moisture Insensitive Primer on the enamel surface
important during tray removal and initial arch wire inser- before the indirect bonding procedure, then the air
tion; and C, bond strength development over 24 hours. syringe should be used to remove excess moisture.
Complete desiccation of the teeth is optional (Fig
16B). A liberal coat of Transbond MIP should be
whether the tray needs to be sectioned into two painted onto the enamel surface. Air dry for
segments is a decision based primarily on the approximately 3 to 5 seconds. Light curing of this
degree of isolation that is feasible. If there is sig- product is not necessary for indirect bonding.
nificant crowding and imbrication of the teeth, it B.If Transbond MIP Moisture Insensitive Primer
may be easier to section the tray. Since the work- is not used, and the bonding is accomplished with
ing time with the indirect bonding resin is virtu- the indirect bonding resin, then all visible mois-
ally unlimited (because the adhesive does not ture should be removed. The etched teeth should
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 359
Volume 115, Number 4

have a frosty appearance and be completely des- strength is demonstrated in pounds per bracket, and a
iccated. If a frosty appearance is not apparent, total of 25 brackets were tested. Fig 10B provides more
repeat the etching process for 15 seconds. important data, since the bond strength immediately
10. Small amounts of the indirect bonding Resin A after curing is of critical importance during tray
and B liquids should be poured into the wells (Fig removal, and initial arch wire insertion. In that test, our
7A). Take care to keep liquids separate. Resin A indirect resin showed substantially greater bond
can be painted onto the tooth surface with a brush, strength than the other resins. After 1 hour, the other
and Resin B can be painted on the resin pads in resins started to catch up (Fig 10C). Eventually, the
the indirect bonding tray (Fig 7B and C) bond strength of all three materials peaked to relatively
11. If too much resin has been placed on the enamel, similar levels. However, the clinical efficacy of this
gently remove the excess with a brush. The over- resin is greatly enhanced by the higher bond strength
all method of painting the resin on the enamel when tested at the 5 minute level. Indirect bonding
and the custom bases is not unlike painting one’s with Concise Enamel Bond has a distinct disadvantage,
fingernails. of course, because of the limited working time, longer
12. Position the tray over the teeth and seat the tray with cure time, and the need to mix the resin. As has been
a hinge motion. With the fingers, apply equal pres- pointed out earlier in this article, this is because Con-
sure to the occlusal, labial, and buccal surfaces. cise Enamel Bond was developed specifically for direct
Hold for a minimum of 30 seconds. Allow 2 more bonding, and the Sondhi Indirect Adhesive has been
minutes of cure time before removing the tray (Fig developed specifically for indirect bonding.
8A). This procedure is now repeated for the oppos-
ing arch (Fig 8B). Because of the rapid set time of DISCUSSION
this adhesive, by the time the opposing tray is A new method for effective and efficient indirect
placed, removal of the first tray can begin (Fig 8C). bonding of orthodontic brackets has been presented. The
Fig 9A-D show the completed appliance placement. custom adhesive bases are easily formed with Transbond
13. Remove the tray by using a scaler to peel the tray XT on APC brackets, and the indirect bonding is accom-
from the lingual to buccal. Use extreme care plished with a new resin developed specifically for this
when removing the tray from around bracket purpose. Bond strength has proven to be excellent, and
wings. Scale the excess resin around the brackets we have used this system for the indirect bonding of
and from the interproximal contacts. Use dental complete dental arches, from second molar to second
floss to check that all contacts are open. molar, on pediatric, adult, and orthognathic cases.
14. An initial arch wire, such as an 0.016 Nitinol I gratefully acknowledge the contribution of Mr Darrell
Heat-Activated Wire can now be inserted. James of 3M/Unitek in the development of the resin reported
in this article. The assistance provided by Mr Steve Fletcher,
RESULTS
Ms Rani Stoddard, and Mr John Lamitie in the preparation of
In treating over 500 patients, our experience with this article is also gratefully acknowledged.
this indirect bonding adhesive has revealed that the
References
bonding is relatively consistent and efficient. Occa-
1. Thomas R. Indirect bonding: simplicity in action. J Clin Orthod 1979;13:93-106.
sional bond failures do occur, of course, and are usually 2. Moin K, Dogon IL. Indirect bonding of orthodontic attachments. Am J Orthod
related to contamination or improper technique. In 1977;72:261-75.
3. Simmons M. Improved laboratory procedure for indirect bonding of attachments. J
those cases, it is a simple matter to section the bonding Clin Orthod 1978;12:300-2.
tray, reapply the adhesive, and reseat the brackets. 4. Silverman E, Cohen M. A report on major improvement in the indirect bonding of
attachments. J Clin Orthod 1975;9:270-6.
Bond strength tests have also proved the efficacy of 5. Scholz R. Indirect bonding revisited. J Clin Orthod 1983;17:529-36.
this resin. The graph illustrated in Fig 10A shows that 6. Moskowitz EM, Knight LD, Sheridan JJ, Esmay T, Kruno T. A new look at indirect
bonding. J Clin Orthod 1996;5:277-81.
bond strength compares favorably with indirect bond- 7. Kasrovi P, Timmins S, Shen A. A new approach to indirect bonding using light-cure
ing using Concise Enamel Bond and Custom IQ. Bond composites. Am J Orthod Dentofacial Orthop 1997;6:652-66.