Trends Biomater. Artif. Organs, Vol 20 (2), pp 000-000 (2007) http://www.sbaoi.

org

Physical Properties and Clinical Characteristics of Ceramic Brackets: A

Comprehensive Review

Ashok Kumar Jena#, Ritu Duggal*, and A. K. Mehrotra#

#
Dept. of Orthodontics & Dentofacial Orthopedics
RAMA Dental College Hospital & Research Centre
Lakhanpur, Kanpur 208024

*Division of Orthodontics
Centre for Dental Education & Research
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029

* Corresponding Author: Dr Ritu Duggal, rituduggal@rediffmail.com

The popularity and clinical uses of ceramic bracket is increasing in the contemporary orthodontics. This article provides
the clinician an up-to-date knowledge on the physical properties and clinical characteristics of ceramic brackets. It
critically discusses the various aspects of ceramic brackets with regards to the composition, types, base characteristic,
physical properties, enamel and bracket fracture, frictional resistance, bond strength, debonding methods, bracket
recycling and potential clinical problems and their managements.

Introduction ceramic materials came into the field of

An expectation of beautiful smiles at the end
of orthodontic treatment is a primary concern
to each patient, but is also equally concerned
with appearance while undergoing treatment.
Many attempts have been made by
manufacturers to meet this demand. This
includes by making metal brackets smaller,
developing lingual or “invisible” brackets,
making plastic brackets and at last
introducing translucent ceramic brackets.
During the early 1970s, plastic brackets were
marketed as the esthetic alternative to metal
brackets. These polycarbonate brackets
quickly lost favor because of discoloration
and slot distortion caused by water
absorption1-6. This led manufacturers to
modify the plastic brackets by reinforcing the
slots with metal and ceramic fillers7. Despite
these alterations, the clinical problems like
distortion and discoloration persisted.
In the mid 1980s, the first brackets made of
monocrystalline sapphire and polycrystalline
orthodontics7,8. They were introduced as an
esthetic appliance which, unlike plastic
brackets, could withstand most orthodontic
forces and resist staining. However, inability
to form chemical bonds with resin adhesives,
low fracture toughness and increased
frictional resistance between metal arch
wires and ceramic brackets were remained
as major disadvantages with ceramic
brackets7,9,10. Recently, a new ceramic
bracket design having metal-lined arch wire
slot was introduced to the market in an
attempt to minimize some of the problems
that were encountered by the clinician. The
advantage of having a stainless steel slot
was to minimize the increased friction that
occurred as a result of the arch wires
contacting ceramics. The metal slot also
helped strengthen the bracket in order to
withstand routine orthodontic torque forces.
Several ceramic brackets are available at
present and their popularity and clinical uses
are increasing in the contemporary
orthodontics. The purpose of this article is to
discuss and present the various aspects of
ceramic brackets used in contemporary
orthodontics.
Composition and Types of Ceramic
Brackets
Ceramics are a broad class of materials
consisting of metal oxide elements and non-
metal elements that include precious stones,
glasses, clays and mixtures of ceramic
compounds11. In essence, a ceramic is
neither metallic nor polymeric. Modern
ceramic engineering has developed new
ceramic materials, with numerous new
applications, by taking advantage of the
properties found in different atomic
structures12. Alumina (A12O3) is a typical
member of modern ceramics, formed when
aluminum is added to steel to remove
oxygen dissolved in the steel11-13. Alumina
may be used as a single-crystal material or
as a polycrystalline material11. Both
monocrystalline and polycrystalline alumina
are used to manufacture orthodontic ceramic
brackets14.
All currently available ceramic brackets are
mainly composed of aluminium oxide.
However, because of their distinct
differences during fabrication, there are two
types of ceramic brackets i.e. polycrystalline
ceramic brackets and monocrystalline
ceramic brackets15-18. The manufacturing
process plays a very important role in the
clinical performance of the ceramic brackets.
The production of polycrystalline brackets is
less complicated, and thus these brackets
are more readily available at present14. The
most apparent difference between
polycrystalline and single crystal brackets is
in their optical clarity. Single crystal brackets
are noticeably clearer than polycrystalline
brackets and hence are translucent.
Fortunately, both single crystal and
polycrystalline brackets resist staining and
discoloration14,19.
Ceramic brackets are available in a variety of
structures including true Siamese, semi-
Siamese, solid, Lewis/Lang and Begg
designs etc. Many brackets are made by
specialized ceramic manufacturers and are
sold under proprietary names by
manufacturers or distributors of orthodontic
products15. Currently available ceramic
brackets and their characteristics are
summarized in table-1. Single-crystal
brackets have noticeably more optical clarity
than polycrystalline brackets but whether the
difference is significant or not is a judgment
to be made by each clinician and patient.
Base Characteristic of Ceramic Brackets
Currently, there are two types of ceramic
bracket bases available. One type of bracket
base is formed with undercuts or grooves
that provide a mechanical interlock to the
adhesive. The mechanical retention of such
brackets is less as compared to other
bracket base that are having both
micromechanical retention and chemical
adhesion20,21. The other type of bracket base
has a smooth surface and relies on a
chemical coating to enhance bond strength.
A silane coupling agent is used as a
chemical mediator between the adhesive
22
resin and the bracket base . It has been
claimed that chemical adhesion provided
higher bond strength when compared with
mechanical retention19.
Recently, another two developments in
ceramic bracket base technology has come
that use polycrystalline alumina with a rough
base comprised of either randomly oriented
sharp crystals or spherical glass particles.
These brackets provide only
micromechanical interlocking with the
orthodontic adhesive20. In an attempt to
overcome the potential damage of enamel
during debonding, a ceramic bracket with a
thin polycarbonate laminate coating on the
base has been manufactured (CeramaFlex,
TP Orthodontics). The bond to the enamel
therefore is not through an adhesive to the
ceramic base but to the thin polycarbonate
laminate. It has been suggested that these
brackets are as easy to remove as metallic
brackets23-25.
Physical Properties of Ceramic Brackets
Ceramics are famous for their hardness and
for their resistance to degradation at high
temperature and to chemical degradation.
Table-1:- Currently available ceramic brackets, their made, composition, slot dimension, prescription and other
characteristics.
Bracket Made Composition Prescription Other
& Characteristics
Slot Dimension
Allure GAC Polycrystalline Standard Translucent brackets, Smooth profile, Diamond
International Edgewise / .018” & cut reheated slot, High under tie wing radii,
.022” Easy to ligated, Dimpled base, Universal omni
Roth Ovation / hooks, Double hooks on canines and upper
.018” & .022” premolars, Have different colour height gauge,
Micro Progressive Colour coded ID on the distogingival tie wings,
/ .018” No mandibular bicuspid brackets, Both
chemical and mechanical retention, Debonding
by squeezing at the bracket- tooth interface by
debonding plier.
Aspire Forestadent Polycrystalline Roth / .018” & Contoured dovetail base, Transparent brackets,
Gold with gold alloy .022” Resistance to stain, Hooks on canine and
slot premolars, Mechanical retention.
Acclaim ClassOne Polycrystalline Standard Rounded slot base, Hooks on canine and
Orthodontics Edgewise / .018” & premolars, Both chemical and mechanical
.022” retention, Debracketing by ligature cutter.
Roth / .018” &
.022”
Bio-Progressive /
.018” & .022”
Ricketts / .018”
Clarity 3M Unitek Polycrystalline Standard Mechanical lock base, Translucent twin
with metal slot Edgewise/ .018” & brackets, APC II, Bidirectional canine and
.022” premolar hooks, Torque in the base, Metal
MBT / .018” & lined slot, Tie wings for easy ligation like metal
.022” brackets, Rounded contour and dome shaped
Roth / .018” & profile for patient comfort, Have prominent
.022” recessed ID dot, Twin design, Base flange for
High torque / .018” easier placement and adhesive flash clean-up,
& .022” Stress concentration allows for metal like
debonding, Debracketing by squeezing the
mesial and distal wings of the metal arch wire
slot with How or Weingart plier.
Cerama TP Polycrystalline Roth / .018” & Only ceramic bracket with flexible and safety
®
Flex Orthodontics .022” base, Safest and most advanced ceramic
Tip-Edge / .022” bracket available, Patented plastic pad, Made
256-Begg bracket from injection molded technique, Stronger and
smoother, Translucent, Resistance to
discoloration, Dovetail notches in the wings,
Unique oval recess in the slot, Base is
compound and contoured, Hook on the cuspid,
Torque in base, Vertical slot in the Roth
system, Colour coded ID system, Debonding by
squeezing the plastic pad with ligature cutter.
Contour ClassOne Polycrystalline Roth / .018” & Mechanical retention, Made from injection
Orthodontics .022” molded technique, Rounded arch wire slot, Low
Lewis and Lang / profile in the mandibular anteriors, Hooks on
.018” canines and premolars in Roth system,
Debracketing by ligature cutters or by band
slitters.
Desire Ortho Care Polycrystalline Roth / .022” Mechanical lock base, Translucent compact
Limited with gold alloy brackets, Hooks on canines and premolars,
slot Torque in the bracket base.
DCA DCA Polycrystalline Standard Twin configuration, Impervious to stains and
Edgewise /.022” discoloration, Mechanical retention, No lower
Roth / .022” cuspid brackets, Hooks on canines and upper
premolars.
Delta Ortho Polycrystalline Delta Force / .022” Pleasing esthetics, Variable ligation, Easy
®
Force Organizers Supertorque / bracket placement, Hooks as standard 5 x 5.
.022”
 T
Eclipse Masel Polycrystalline Roth / .018” & Mechanical retention, Translucent and stain
M
.022” resistance brackets, Twin brackets, Low profile
design, Beveled lower incisors brackets,
Reinforced tie wings, Hooks on canines and
premolars, Debracketing with ceramic
debonding pliers as recommended by the
manufacture.
T
Encore Ortho Polycrystalline Standard Translucent brackets, Generous contoured tie
M
Technology with silver Edgewise / .018” & wings, Dovetail base for mechanical retention,
alloy slot .022” Colour coded ID system, Hooks on canines and
Roth / .018” & premolars.
.022”
Fascinat Dentaurum Polycrystalline Roth / .018” & Manufactured by two step sintered process,
®
ion 2 .022” Optimum translucency, Excellent colour
Standard stability, Twin design, Smooth surface,
Edgewise / .018” & Rounded contours, Silane coated base, Hooks
.022” on canines, Innovative button structure base,
Easy to debond, Strength and functions are
comparable to metal brackets, Positioning
guide.
Illusion Ortho Polycrystalline Roth / .018” & Dovetail base, Mechanical retention,
TM
Plus Organizer with or without .022” Translucent brackets, Compound and
silver alloy slot Bio-Progressive / contoured design, Resistance to staining,
.018” & .022” Grooved base and porous surface, Colour
coded ID system, Torque in the base, Hooks on
canines and premolars.

Integra Ortho-Byte Polycrystalline Standard Transparent, Stain resistance, Mechanical

Edgewise / .018” & retention, Low profile design, Radiopaque,
.022” Hooks on canines and premolars.
Roth / .018” &&
.022”
Inspire Ormco Monocrystallin Roth / .018” & Translucent true twin brackets, Made by Boron
TM
Ice e Sapphire .022” carbide tumbling process and ultra smooth heat
polished surface, Mechanical ball base design
for mechanical retention, Tooth specific pad
contour, Face-paint identification system.
T
Intrigue Lancer Polycrystalline Standard Translucent, Grooves in the base, Mechanical
M
Orthodontics Edgewise / .018” & retention, Torque in the base, Colour coded site
Ortho Care .022” tabs, Hooks on canines and premolars.
Limited Roth / .018” &
.022”
®
InVu TP Polycrystalline Standard Injection molded, Low profile, Twin design,
Orthodontics with polymer Edgewise / .018” & Smooth surface, Rounded arch wire slots, Ball
crystal mesh .022” end hooks in canines, Crystal mesh base
base Roth / .018” & protect enamel and debonds like metal,
.022” Debracketing by ligature cutters.
MBT / .018” &
.022”
TM
LUXI II RMO Polycrystalline RMO version of Translucent, Low profile, Twin design, Nickel
with 18-karat Roth / .018”&.022” free gold slot inserts, Dovetails for mechanical
gold insert retention in the base, Torque in the base,
Hooks on canines and premolars.
Monarch ClassOne Polycrystalline Roth / .018” & True twin wing brackets, Better rotational
TM
Orthodontics .022” control, Hooks on canines and premolars,
Debonding by ligature cutters.
®
MXi TP Polycrystalline MXi Straight-Edge Injection molded, Smooth surface, Rounded
Orthodontics with polymer / .018” & .022” slots, Countered edges, Crystal mesh base
crystal mesh MXi Advant-Edge / protects enamel and debonds like metal,
base .018” & .022” Debonding by ligature cutters.
MXi Tip-Edge /
.022”
MXi 256-Begg
Mystiqu GAC Polycrystalline Standard Translucent, Stain resistance, Low profile,
®
e International Edgewise / .018” & Metal free diamond cut silica lined slot, NSB
TOC .022” base, Torque in base, Double omni hooks on
Roth Ovation / canines and premolars. No lower bicuspid
.018” & .022” brackets to prevent enamel abrasion,
Micro-Progressive Debonding by Mystique 346RT or Mystique
/ .018” & .022” 1026.
Reflectio Ortho Polycrystalline Standard Injection molded, Transparent, Stain
TM
ns Technology Edgewise / .018” & resistance, Generous contoured tie wings,
The Dental .022” Dovetails for mechanical retention, Colour
Directory Roth / .018” & coded ID system, Hooks on canines and
.022” premolars.
MBT / .018” &
.022”
Signatur RMO Polycrystalline RMO version of Dovetails for mechanical retention, Torque-in-
TM
e III Roth /.018”&.022” base, Underwing notches for easy ligation,
Standard Hooks on canines and premolars with Roth.
Edgewise / .018” &
.022”
Ricketts / .018”
Bio-Progressive /
.018”
Starfire ‘A’ Company Monocrystallin Andrews / .018” & Only clear bracket on the market, Only straight
TMB Orthodontics e .022” wire aesthetic bracket on the market, Color axis
Roth / .018” & indicators for easy identification and placement,
.022” Available with and without mesial and distal
Super-torque / hooks, Debonding by the special pliers
.018” & .022” recommended by the manufacturer.
(Upper only and
canine to canine)
Transce 3M Unitek Polycrystalline Standard Microcrystalline lock base, Underwire tie-wing
TM
nd Edgewise / .018” & protector, Radiused corners and edges for
Series .022” patient comfort and esthetics, Underwire tie-
6000 Roth / .018” & wing protection ensure the labial tooth surface
.022” from out of contact with Alastik ligatures, Colour
High Torque / coded indicators, Adhesive coated (APC),
.018” Hooks on canines and premolars, Unique
Ricketts micro-crystalline bonding surface for reliable
mechanical retention, Debracketing by
Transcend series 6000 debonding instrument.
TM
Virage American Polycrystalline Roth / .018” & Dovetails grooves and mechanical lock base
Orthodontics with palladium .022” for mechanical retention, Stain and fracture
gold alloy MBT / .018” & resistance, 100% nickel free metal slots
inserts .022” (Diffusion bonded slot), Smooth rounded
contour, Colour coded ID, Hooks on canines
and premolars, Debracketing by ligature cutters
or bracket removers.
20/40m American Polycrystalline Standard Strongest ceramic brackets on the market,
Orthodontics Edgewise / .018” & Small brackets with smooth harder surface,
.022” Translucent, Twin design, Rounded slot
Roth / .018” & corners, Generous tie-wing undercut for easy
.022” ligation, Colour coded ID system (In slot itself in
Standard Edgewise system), Bevel on the
lower anteriors which reduces occlusal
interferences and eliminate enamel wear,
Streamline hooks on canines and premolars
with Roth. Mechanical retention.
The physical properties of ceramics are a
result of their atomic bonding11,26. Ceramics
are primarily bound together with ionic and
covalent bonds, which are strong and
directional. Ionic bonds, which are stronger
than metallic bonds, form when a metal atom
gives up its valance electron(s) to the outer
shell of a non-metal atom, resulting in
positive and negative ions which attract each
other. Covalent bonds, the strongest type,
occur when atoms of the same element or
different elements share electrons. When
stress is applied, the crystals fracture in a
brittle fashion, because these bonds do not
permit slip planes, which allow plastic
deformation, to form11,13,26,27. The physical
properties of ceramics which are important to
the orthodontics include hardness, tensile
strength and fracture toughness or
brittleness.
Hardness
A very important physical property of ceramic
brackets is the extremely high hardness of
aluminium oxide. This adds a significant
advantage to both monocrystalline and
polycrystalline ceramic brackets over
stainless steel brackets15. Ceramic brackets
are nine times harder than stainless steel
brackets or enamel14, and severe enamel
abrasion from ceramic brackets might occur
rapidly, if contacts between teeth and
ceramic brackets exist18,28.
Tensile Strength
The tensile strength is much higher in
monocrystalline alumina than in
polycrystalline alumina, that is in turn
significantly more than stainless steel14,15,29.
This is the reason that the only true Siamese
brackets made from ceramic material have
been produced from monocrystalline
alumina15. Tensile strength characteristics of
ceramics depend on the condition of the
surface of the ceramic14,30-32. A shallow
scratch on the surface of a ceramic bracket
drastically reduces the load required for
fracture. The elongation for ceramic at failure
is less than 1% in contrast with
approximately 20% of stainless steel, thus
making ceramic brackets more brittle14,30,31.
In other word metal brackets deforms 20%
under stress before fracturing, whereas
ceramic brackets deforms less than 1%
before failing.
Fracture Toughness or Brittleness
Ceramics used in orthodontic brackets have
highly localized, directional atomic bonds.
This oxidized atomic lattice does not permit
shifting of bonds and redistribution of stress.
When stresses reach critical levels, the
interatomic bonds break and material failure
occurs. This is called "brittle failure". Fracture
toughness in ceramics is 20 to 40 times less
than in stainless steel14,31, making it much
easier to fracture a ceramic bracket than a
metallic one. Among ceramic materials,
polycrystalline alumina presents higher
fracture toughness than single-crystal
33,34
alumina . The brittle nature of ceramic
brackets has resulted in a higher incidence
of bracket failure (fracture) during
22,31,35,36
debonding . Ceramic compounds,
unlike metals, are also susceptible to crack
propagation caused by minute imperfections
or material impurities. High-strength
ceramics can fail relatively easily when
cracks or imperfections allow for local
concentrations of stresses. The fracture
toughness of the enamel is lower than that of
ceramic31 and ceramic brackets bonded to
rigid, brittle enamel have little ability to
absorb stress14. Enamel fracture or the
appearance of fracture lines during
debonding is related to the high bond
strength of ceramic brackets and seems to
be associated with sudden impact
loading37,38.
The combination of very hard and brittle
properties and high bond strength leads to
reports of two significant problems. One is
bracket fracture specifically during
debonding and another is enamel fracture
which may occur during function38 but mostly
during debonding7,39. Ceramics are
radiolucent and if swallowed or inhaled
would not be visible on the radiograph.
Why Enamel and Bracket Get Fracture?
The occurrence of the enamel fractures is
due to the high bond strength of ceramic
brackets. The mean bond strength for the
different bracket, adhesive and enamel
conditioner combinations ranged from a
minimum of 3.9MPa to maximum of
18.6MPa40. Minimum bond strength of
5.9MPa to 7.8MPa was found to be
adequate for most clinical orthodontic
needs41. However, most of the adhesives
available on the market have bond strength
between 5.9MPa to 11.3MPa40,42 and few
studies reported maximum of 29.4MPa43,44.
The shear bond strength of ceramic brackets
was found to be more than stainless steel
brackets19,24,43,45. The mean linear tensile
strength of enamel is 14.5MPa46. Thus,
when the force required to remove the
bracket from the enamel exceeds the mean
linear tensile strength of the enamel or the
bracket itself, fracture of the enamel surface
or the bracket takes place. Retief reported
that enamel fracture can occur with bond
strengths as low as 13.5MPa which was
comparable to the linear tensile strength of
the enamel47. Therefore, a debonding
technique that reduces the required forces
for debracketing reduces the risk of enamel
fracture.
Frictional Resistance
It was found that under all conditions tested,
stainless steel brackets had less frictional
resistance than ceramic brackets; and this is
most likely a result of their lower surface
roughness10. Polycrystalline brackets have a
higher co-efficient of friction than
monocrystalline ceramic and stainless steel
brackets. This is due to their rougher and
more porous surface. Keith et al. however
did not find any significant advantage of
monocrystalline brackets over polycrystalline
ceramic brackets with regards to their
frictional characteristics48. The co-efficient of
friction of monocrystalline and stainless steel
brackets is however comparable. Ceramic
brackets manufactured by milling or
machining with diamond tools produced
significantly greater rough surface. Omana,
Moore and Bagby reported that ceramic
brackets manufactured by injection-molding
technique had less friction than other
ceramic brackets49. They also found that
wider brackets had less friction than
narrower brackets of the same material.
Comparison of frictional forces produced in
ceramic and stainless steel brackets, when
different wires were used, suggested that for
most sizes, the wires in ceramic brackets
produced significant greater friction. Also,
beta-titanium and nickel-titanium wires were
associated with higher frictional forces than
stainless steel or cobalt-chromium
wires9,10,45,50-52. To reduce frictional
resistance, development of ceramic brackets
with smoother slot surfaces and consisting of
metallic (stainless steel and gold), silica
lining or ceramic/plastic slot surfaces was
considered and presently accomplished45.
Another recent modification to further reduce
friction is the introduction of bumps along the
floor of the bracket slot53. Unfortunately, the
bumps did not appear to reduce classical
friction as ceramic brackets with a single
bump to the slot floor produce similar rates of
binding to the conventional design53.
Bonding Ceramic Brackets
Mechanisms for bonding ceramic brackets
include mechanical retention, chemical
bonding or a combination of both.
Mechanical retention is achieved through
indentations and/or undercuts in the bracket
base. Laboratory testing of mechanical
retention indicates that adhesive-to-bracket
bond strengths are less than those of
equivalent-size foil/mesh metal brackets.
Ceramic bracket bases have considerably
fewer mechanical undercuts than are found
in mesh base designs, and therefore the
ceramic brackets might be expected to have
greater bond failure rates. Debonding is
much easier with a mechanical interlock
because bond strengths are apparently
marginal. Chemical bonding is a more recent
development in which glass is added to the
aluminum oxide base and treated with a
silane coupling agent. The silane bonds with
the glass and has a free end of its molecules
that reacts with any of the acrylic bonding
materials. It produces exceptional bond
strengths, but these can possibly exceed the
brittle fracture resistance of the thinner areas
of a ceramic bracket. The stresses of
debonding can also be shifted from the
bracket-adhesive interface to the adhesive-
enamel interface. A rigid, brittle ceramic
bracket bonded to rigid, brittle enamel has
little ability to absorb stresses. If the bracket-
to-adhesive bond is too strong, then failure
can only occur within the ceramic, within the
adhesive, or within the enamel. A sudden
impact loading is more likely to cause failure
in the more brittle ceramic and enamel than
in the polymeric bonding material.
Bond Strength
The different bond strength between
mechanical and chemical bonding is due to
the way stress concentration is distributed
over the bonding surfaces. Ceramic brackets
that offer a mechanical bond with the
adhesive have retentive grooves in which
edge angles are 90 degree43. There are also
crosscuts to prevent the brackets from
sliding along the undercut grooves that have
sharp edge angles, thus leading to high
localized stress concentrations around the
sharp edges and resulting in brittle failure of
the adhesive. On application of shear
debonding force, part of the adhesive
remained on the tooth and part on the
grooved bracket19. On the other hand, the
shiny surfaces of ceramic brackets bonded
chemically allow a much greater distribution
of stress over the whole adhesive interface
without the presence of any localized stress
areas. Consequently, significantly greater
shear bond was needed to cause debonding
and pure adhesive failure19.
Bond strength can be affected not only by
the bracket base design, but also by various
other factors including type of bonding resin,
etching time, condition, and preparation of
teeth involved54,55. Many studies concluded
that the shear bond strength of
polycrystalline ceramic brackets was
significantly greater than that of stainless
steel brackets19,24,43,55,56. Monocrystalline
brackets however had higher shear bond
strength than a polycrystalline structure57.
Debonding Ceramic Brackets
As the properties of ceramic brackets differ
significantly from those of the metallic
brackets, techniques for removing bonded
metallic orthodontic attachments are not as
effective as with ceramic brackets and thus
special debracketing techniques are
recommended.
The first technique used for debonding
ceramic brackets was mechanical.
Manufacturers have produced special
instruments or pliers for debonding their own
ceramic brackets, although the A-Company
Starfire debonding pliers may be used to
15
remove any bracket . The pliers cause
either deformation of the bracket, thus
breaking the bond at the bracket-adhesive
interface or by stressing the adhesive to its
ultimate strength causing cohesive failure
within the composite resin. Sometimes
failure may occur at the adhesive-enamel
interface40. The force required for
mechanical bond failure is very high and thus
leads to enamel and bracket fracture. Swartz
recommended that ceramic brackets should
be debonded with a sharp-edged instrument
(ligature cutter) placed at the enamel-
adhesive interface, and a "slow gradual
squeezing" force should be applied until
bracket failure occurs22.
Raising the temperature of the bracket-
adhesive interface to 520C had been shown
to reduce the mechanical force required for
debonding by approximately half58. Handi-Dri
tooth dryer marketed by Lancer orthodontics
and hot tips of plier were used to heat the
bracket-adhesive interface. Carter
recommended hot-water bath to facilitate
debracketing of ceramic brackets59. Raising
the temperature of bracket-adhesive
interface helped to peel away the bracket
from the adhesive.
An electrothermal debonding technique has
been suggested as an alternative method to
thermal heating. It involves heating the
bracket with a rechargeable heating gun
while applying a tensile force to the
bracket60,61. The electrothermal technique
was found to be quick, effective and devoid
of either bracket or enamel fracture62. One
concern with this method is related to the
potential for pulp damage, because a
significant rise in pulp temperature may
result in pulp necrosis58,63. However,
subsequent investigations found that the
heating temperature during electrothermal
debonding was too low and the heating time
was too short for pulp damage64, unless the
adhesive material used required many
heating cycles before separation and air
cooling was not used simultaneously65,66.
It has been suggested that a chemical agent
can contribute to easier mechanical
debonding. Post-debonding agent (GAC
International Inc.) and P-de-A (Oradent Ltd.)
are derivative of peppermint oil should be
applied around the bracket base before
mechanical debonding. According to this
method, ceramic bracket removal was be
facilitated and bond failure took place at the
adhesive-enamel interface, without
damaging the tooth surface25. It neither
produces any significant effect on the
surface micro-hardness of orthodontic resins
nor softens the resin matrix but allowed
easier debonding of orthodontic
appliances67. Laboratory studies had shown
that a 60-second application of peppermint
oil facilitated ceramic bracket removal and
promoted failure at the adhesive-enamel
interface, without damaging the tooth
surface68.
An ultrasonic debonding technique has been
used to create a purchase point within the
adhesive between the bracket base and the
enamel surface. In this technique, the
brackets are debonded with KJS ultrasonic
tips and the Cavitron 2002 ultrasonic unit
(Dentsply International)6. The advantages of
the ultrasonic debonding approach include a
decreased chance of enamel damage, a
decreased likelihood of bracket failure and
the ability for the removal of the residual
adhesive with the same instrument after
debracketing62. Many authors found bond
failures at the enamel-adhesive interface
with this approach62,69. However, there are a
number of disadvantages associated with the
ultrasonic technique, including a significantly
increased debonding time, excessive wear of
the expensive ultrasonic tips, the need to
apply moderate force levels, which could
create some discomfort to sensitive teeth,
the potential for soft tissue injury by a
careless operator, and the need for a water
spray to reduce the heat build-up and to
minimize any possibility of pulpal damage.
Since the ultrasonic method is effective but
time consuming, its use might be indicated
when a ceramic bracket fractures while the
conventional method is being used and part
of it remains attached to the tooth.
The use of lasers (Nd:YAG and CO2)for
debonding ceramic brackets has been
investigated70,71. The proposed laser-aided
debonding technique was found to
significantly reduce the residual debonding
force, the risk of enamel damage and the
incidence of bracket fracture as compared
with the conventional methods. This
technique has the potential to be less
traumatic and painful for the patients and
less risky for enamel damage70,71. It was
found to favor bond failure at the bracket-
adhesive interface with no bracket or enamel
damage72. After CO2 laser illumination for 2
seconds the average torque force necessary
to break the adhesive between the
polycrystalline ceramic brackets and the
tooth was lowered by a factor of 2570.
Similarly the average torque force needed to
debond monocrystalline brackets was
lowered by a factor of 5.270. Stroble et al.
concluded that the debonding mechanism
was thermal softening of the resin adhesive
by the laser induced heat which transmitted
through the bracket to the resin70. Actually
laser-initiated resin degradation can occur as
the result of either thermal softening or
thermal ablation or photoablation.
Recycling of Ceramic Brackets
Ceramic brackets are much more brittle than
conventional metallic brackets and therefore
are more likely to fracture than to distort on
debonding. The intact debonded brackets do
not lose their precisely machined angulation,
torque, and base contour. Recycling of
debonded or dislodged brackets provides a
substantial savings in the expense of
maintaining a bracket inventory. A method of
recycling ceramic brackets was suggested
by Lew and Djeng73. In recycling procedure,
first any composite resin remaining on the
bracket base should be removed by holding
the bracket with a pair of tweezers and
heating it in a Mini-Torch until it turns cherry
red. After it the bracket should be allowed to
cool until it reaches room temperature and
the residual composite which appear as
chalky white and flaky should be removed by
gently tapping the bracket on a table top or
by lightly scraping the base with a wax knife.
Than the base should be dried and cleaned
with compressed air to remove any possible
residue followed by rinsing it in 100 percent
isopropyl alcohol or-pure acetone. To restore
the silane layer on chemically treated bases
or, if desired, to improve the retention of
mechanically interlocking bases, a thin layer
of a porcelain primer should be applied with
the help of a brush. Before applying the
porcelain primer, phosphoric acid etchant
with a cotton pellet should be applied on the
base for 60 to 90 seconds. The acid should
not be rinse off, because it is used to
hydrolyze the hydrogen atoms and hydroxyl
groups in the silica surface. After this
porcelain primer should be applied over the
acid and left it on the surface for one minute
before rinsing and drying thoroughly. After 10
minutes of air drying, the primed brackets
should be bonded to the etched enamel
surfaces with either a chemically or light-
cured composite resin. Comparison of
debonded ceramic bracket bases with those
of recycled brackets after heating and
application of the silane coupling agent
suggested that the "recycling" method was
effective in providing a clean surface73. Bond
strength of recycled brackets was appeared
to be clinically adequate, although it was
significantly lower than that of new brackets.
This weaker bond strength after "recycling"
of ceramic brackets however minimized the
likelihood of unwanted enamel removal
during debonding74.
Optimizing Ceramic Bracket Performance
Ceramic brackets have the potential to meet
the practitioner’s demand for excellent
performance, as well as the patient’s
demand for superior esthetics. Of course,
like any new material, ceramics may require
technique modifications.
One of the major causes of ceramic bracket
breakage during treatment is due to torquing
force. It is advisable to use proper wire
sequence during leveling and alignment
phase instead of using thick stainless steel
wire prematurely. Use of sequential nickel
titanium rectangular archwires helps easier
insertion of stainless steel rectangular wires
later, with less chance of bracket breakage.
Treatment with sliding mechanics is
expected to proceed very slowly with any
type of arch wire-ceramic bracket
combination. Traditionally with metal
brackets, closing loops are used for closing
extraction spaces and power chain for
smaller spaces. With ceramic brackets, it is
advisable to use closing loops even for small
spaces. Enamel abrasion or wear can
appear suddenly where teeth come in
contact with ceramic brackets. Any patient
considering ceramic appliances should be
informed of the potential for enamel
abrasion. Additionally, a patient with a deep
bite or a history or evidence of bruxism
should start treatment with a reverse-curve
nickel titanium wire, which will immediately
begin to open the bite. The mandibular
brackets should also be positioned more
gingivally than usual. If wear is noted within
the first month or two, a bite plane should be
considered. Alastigard ligatures (elastomeric
ligatures with pads) can be used where
brackets come in contact with teeth. In some
situation it is advantageous to bond only the
upper arch until some leveling and aligning
have occurred. Brittleness of the tie wings is
most problematic in ceramic brackets. It is
advisable to avoid heavy forces. During
torquing nickel titanium wire should be used
because of their springiness and rounded
edges. Ligature wires should be Teflon-
coated and never larger than .010". If
possible elastomeric ligatures should be
used. Hooks should be bent, soldered, or
clamped to the wires instead of tied to the
brackets.
Potential Clinical problems and Their
Management
Various complications during the use of
ceramic brackets in clinical practice are
common. The major problems include
enamel fracture during debonding, bracket
fracture, increased friction, patient discomfort
during debonding and attrition of teeth
occluding against the bracket. Various
measures to overcome these problems are
discussed.
Problem 1: Enamel fracture during
debonding.
Enamel fracture during debonding is related
to the high bond strength of ceramic brackets
and sudden impact loading37,38. Enamel
fracture during debonding can be prevented
by avoiding sudden impact loading or stress
concentration within the enamel by using
proper debonding techniques75, avoiding
bonding of ceramic brackets on structurally
damaged teeth i.e. teeth having crack lines,
heavy caries, large restorations, hypoplasia,
55
hypocalcification and nonvital tooth and by
reducing the bond strength of ceramic
brackets by adding mechanical retention19,37,
76
by reducing chemical retention , by adding a
metal mesh at the base of the bracket, by
reducing the base area of the brackets, by
76,77
using weaker resins , by adding extra
plasticizer to the resin78, by modifying the
thickness of adhesive used79, by modifying
the etching time and/or concentration of
etching acid (H3PO4)4,80,81 and by debonding
with ultrasonic, electrothermal and laser
devices6,62,82,83.
Problem 2: Removal of broken ceramic
brackets by grinding.
When a proper debonding technique fails,
and/or risks subjecting the tooth to increased
forces and fracture, grinding the ceramic
bracket becomes the option of choice.
Grinding should be carried out with high-
speed diamond burs or low-speed green
stones. The procedure is time-consuming
and the heat which generated by grinding
might affect the dental pulp and
84
subsequently, the vitality of the tooth . Such
problem can be managed by reducing the
size of ceramic bracket to be ground by
fracturing the tie wings with ligature cutting
pliers, and avoiding the build up of heat
during grinding. Air or water coolant must be
used while grinding the bracket to avoid a
rise in pulp chamber temperature14.
Problem 3: Attrition of teeth occluding
against ceramic brackets.
It represented the highest percentage of
injury from ceramic brackets85. It is due to the
fact that ceramic brackets are harder than
enamel18,28,86,87. Such problem can be
overcome by selecting the teeth to be
bonded with ceramic brackets. The clinician
must avoid bracket contact with opposing
teeth. In deep anterior overbite cases,
bonding the mandibular teeth with ceramic
brackets should be avoided. Similarly in
cases where the maxillary canine is retracted
past the mandibular tooth, bonding the
mandibular canine should be avoided.
Problem 4: Increased friction with ceramic
brackets.
High friction is due to the roughness of the
bracket interface which slows the sliding of
10,36,50,87
the archwire through the bracket .
This clinical problem can be managed by
using ceramic brackets with smoother slot
surfaces i.e. by incorporating metal slots and
by strengthening the anchorage
requirements.
Problem 5: Breakage of ceramic brackets.
This is due to the low fracture toughness of
the ceramic brackets88. It often affects
bracket wings and usually occurs
accidentally when cutting ligature wires or
engaging a heavy archwire in the bracket.
Sometimes the slightest torque of such wire
in the bracket interface leads to fracture4.
Such problem can be avoided by avoiding
direct contact of the brackets while cutting
ligature wires and forceful engagement of
increasingly heavy archwires used for
leveling. Successive archwires should be
fully engaged in the brackets. Also, it may be
safer to avoid using ceramic brackets in
people prone to trauma because of
professional or numerous sports activities,
such as football, martial arts or other contact
sports.
Problem 6: Increased pain or discomfort
while debonding ceramic brackets.
This is related to the higher bond strength
and it can be managed by having patient bite
with pressure on cotton roll and/or gauze
during debonding.
Problem 7: Esthetic results that is not bracket particles if the bracket fractures
absolute. during debonding89. Because of their
radiolucency, ceramic brackets may not be
Although ceramic brackets hold a definite
detected on radiographs if aspired. Also,
advantage over plastic attachments, some
during debonding, fractured fragments may
polycrystalline brackets do stain. This is
subject the patient to oral soft tissue
probably due to prolonged use of caffeine
damage, and the patient, clinician and
(coffee, tea, colas), certain mouthwashes or
assistant to eye injury. The solution for this is
lipstick, and may also be associated with the
14,45 to use caution and protective equipment
type of bonding resins used . It is
during bonding and debonding. Instructing
necessary to avoid excessive use of staining
the patient to bite on a cotton roll during
substances and discoloring resins. Ceramic
debonding helps reduce the risk of
brackets may look discolored when the
dislodging brackets and/or fragments into the
brackets themselves stain (direct
oral cavity and throat. The clinician and
discoloration) or when stains on the teeth or
assistant should wear protective glasses and
bonding resin show through the bracket
a mask. The patient should wear protective
(indirect discoloration). It tends to occur with
glasses as well or at least keep both eyes
polycrystalline brackets which represent the
shut.
majority of the ceramic brackets
manufactured and so, are most commonly Conclusion
used. Using two-base resins, which tend to
Ceramic brackets are popular as an esthetic
discolor less than no-mix one-step bonding
appliance in the contemporary orthodontics.
resins, has been advocated by Swartz who
Its introduction is a much-heralded
also suggested the light-cured resins may
development in the orthodontic treatment of
offer "excellent color stability14.
adult patients. The acceptance of ceramic
Problem 8: Operational risks. brackets by the patients has been
unprecedented in the practice of orthodontics
The primary operational risk for the patient is
and contributed significantly in the expansion
the accidental ingestion or aspiration of a
and development of contemporary
bracket during bonding or debonding or of
orthodontic therapeutic modalities.

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