Dr.MUHSINA .

E
SECOND YEAR PG
DEPARTMENT OF ORTHODONTICS
 Introduction
Tooth movement is made possible by
an orthodontist by applying an optimal
force Through Archwires,loops,springs,
elastics,etc-in rigid attachment-bracket
 Proper bracket placement is crucial in
orthodontic treatment and with a suitable
arch wire provides the desired mechanical
effect. Imprecision in bracket location may
lead to unwanted tooth movement:
 Bracket can be attatched by
 1-banding
 2- bonding
 MAGILL was the 1 st to use plain band.
 Preformed steel bands came into widespread
use during the 1960s and are now available in
anatomically correct shapes for all the teeth.
  that will receive heavy intermittent forces
( for the anchorage purpose(-extraction
cases) against the attachments for the extra
oral force like Head gear. E.g.: upper 1 st
molars
BONDING

 For the past 50 years,since the introduction

of acid etching by Buonocore in 1955,
major improvements were achieved in
bonding brackets to the teeth.

 In 1964,Newman first tried to bond
orthodontic brackets to teeth using acid
etch technique and an epoxy-derived resin.
Bonding – several advantages and disadvantages over
Banding
Advantages -
1.esthetic superiority
2.faster and simpler
3.less discomfort to the patient
4.arch length is not increased
5.Bonds are more hygienic than bands
6.Mesiodistal enamel reduction is possible
7.Interproximal areas are accessible for composite buildups
8.Caries risk under loose bands is eliminated
9.No band spaces are left behind
10.No large inventory of bands
11.Lingual brackets, invisible braces
12.Brackets may be recycled further
reducing cost
Disadvantages
Weaker attachment
Gingival problems
The protection against well
contoured bands is absent
Debonding is more time consuming
 There are two main techniques of bracket placement.
The first one, more popular, is direct bonding: the
braces are adjusted directly on patients’ teeth.  
 The second technique is called indirect bonding. The
appliance position is planned and fixed on a plaster
model and then transferred into the oral cavity.
Indirect bonding is a precise and time-saving method
of bracket placement, growing in popularity in recent
years
 Several techniques for indirect bonding are available.
Most are based on the procedures described by
Silverman and Cohen ( JCO 1976)
1.Direct bonding - can be
a. chemical cured
b.light cured composite
c.glass ionomer cement
 2.Indirect bonding –
 a.light cured composite (transbond
XT)
 b.thermally cured (therma cure)
 C.chemical cured (sondhi rapid set)
The bonding procedure in short
1cleaning
2. enamel conditioning
3. sealing
4. bonding
a. transfer b.
positioning c.
fitting d.
removal of excess
 The first three steps are same for both
direct and indirect bonding
 Cleaning
pumice- plaque and organic
pellicle are removed
rubber cup or polishing brush is
also used
 Enamel conditioning A.
moisture control After
pumice-salivary control and dry working
field should maintained by
1.cheek retractors 2.saliva
ejectors 3.tongue guards
with bite blocks 4.salivary duct
obstructers
 5. Cotton or gauze rolls
6. antisialogogues-
banthine,probanthine,
atropine sulphate etc
..both tablets and
injections ..PB inj are no
longer advised
..antisialogogues are generally not
 banthine tab-50mgs/100lb-15
minutes before bonding
 only under supervision of the
patients physician
 Sealing
Nothing but an intermediate resin
dry the
teeth-thin layer of sealant applied
by Foam pellet or brush with a
single gingivo- incisal stroke
The sealant coating should be thin
and even
 Bonding
1. transfer
2. positioning
3. fitting
4. removal of excess
 excess adhesive should be
removed
 excess adhesive when not
removed-discolored
 These three procedures are
the same for direct and
indirect bonding techniques
Good bond strength is
dependent on
1.avoiding moisture contamination
2.achieving
undisturbed setting of bonding
adhesive
3.use of a strong adhesive
1960s, the procedure of bonding had many limitations
 . Epoxy adhesives used in the pioneering study had
prolonged curing times. It required 15–30 min to
achieve a gelling phase and maintain the bracket in
a proper position. Due to the fact that final hardness
was only reached after four days, it was impossible
to insert an arch wire and apply the force in one visit
 Extraoral bracket adjustment served as a foundation
of Silverman’s idea- indirect bonding
Indirect
bonding..
The indirect bonding
technique was introduced
by Dr. Silverman and
Cohen in 1972 AJO
several techniques are available-
generally
-the brackets are attached to the
teeth on patients model, transferred
to the mouth with some sort of tray
to which the brackets get embedded
and then bonded simultaneously
• The clinical procedure
techniques differs based on
•the way brackets are attached to the model
•type of transfer tray
•adhesive or sealant used
•the way transfer is removed
An over view of the indirect
bonding
technique
a. Take an impression and pour with stone.
Model- should be dry ,Long axis and occlusal
height marked
b. Select brackets
c. Apply water soluble adhesive
 e. Mix putty silicone and press it
onto the cemented brackets
f. Immerse model and tray in hot
water. Remove any remaining
adhesive
g. Trim the silicone tray and
mark the midline
h. Prepare the patients teeth
i. Load adhesive-bracket base
 j. Seat the tray on the prepared
arch-3 minutes
k.Remove tray after 10 min. tray
must be cut longitudinally or
transversely
l. Complete bonding by careful
removal of excessive flash
 in this technique the transfer tray is
removed before completion of bonding
bracket- failure can be seen

 Modifications
Several methods – bonding resins, sticky
wax etc
Dr. Michael.D.Simmons-1978--JCO-
caramel candy softened and preloaded in
syringe.
Small amount of caramel is warmed to
approx 500c –loaded
0
 A small amount is squeezed onto
each tooth to be bonded. The brackets
are then held with cotton pliers warmed
slightly in Bunsen burner and then
placed on the teeth.
Rest of the procedure is similar.
Thomas’ method

In 1979, research was conducted to improve the

effectiveness of the indirect bonding
technique, resulting in the development of
custom-made bracket bases. In Thomas’
method, brackets were attached to the
previously prepared model with chemically
cured composite
.
 Consequently, a precise bonding pad,
including the bracket with the composite
resin, was created for each tooth.
 In the next step, a transfer was used to
reproduce the position of the brackets
intraorally and the appliance was attached on
the teeth using the two-part unfilled resin.
 The first thin layer of adhesive covered the
bracket pads. The second component of resin, a
sealant, was spread on the enamel surface.
 Adhesion between tooth and orthodontic bracket
was obtained as a consequence of chemical
reaction.
 The method was precise, but insufficient bond
strength was observed. Moreover, the transfer
tray was not transparent, and the optimal
amount of cement was hard to achieve.
Since one of the major difficulties with
indirect bonding… double tray
technique- introduced by
Elliott.M.Moskowitz and Douglas Knight-
1996 may JCO
Thermal cured composite [unlimited
working time] and
vinyl polysiloxane [flexible but highly
accurate under tray]
 Apply thermacure composite to
the mesh pad of each bracket-cast.
Cast in heated oven -15 min at
325 F. After cooling remove.
o

Apply vinyl polysiloxane over

thermally cured brackets.
Adapt the vacuum formed Essix
clear thermoplastic material over the
cast, brackets and under tray comp.
Chair side bonding
procedure. 1. Lightly
abrade adhesive-diamond bur or
simply scrape 2. Isolate,
etch, rinse and dry as usual.
3. Apply
bonding agent-tooth and adhesive –
bracket bases and seat the tray.
 4. Remove the clear over tray.
5. Tease the flexible under tray-
explorer or scaler without
dislodging the brackets.
Advantages… The
under trays are accurate, stable and
compact and will not dislodge the
brackets from teeth when removed
3. Light cured indirect
bonding. JCO-
1998--Michael
Transfer tray-silicone based,
addition cured elastomer
[Memosil]--stiff enough but easily
removed . 1. Coat labial surface
of teeth with thin layer of Poly vinyl
 2. Brush a thin layer of unfilled
resin onto each bracket base-light
cure it for 30 sec.
3. Add the filled composite to
bracket bases-brackets on the casts.
4. Cure each bracket-30 sec
from occlusal and 30 sec form
gingival.
5. Adapt the transfer tray.
 6. Soak the tray in cold water for
20 min.
7. Etch the teeth to be bonded as
usual. Paint thin layer of unfilled
resin over the etched enamel and
over the cured composite
8. Place the transfer tray in the
mouth and light cure each tooth for
30 sec.
4.Thermal cured, fluoride
releasing indirect bonding
system. JCO-1998-
Sinha,Nanda Modification of
previously described IB with
Therma cure. Failure to remove
excess adhesive-accumulation of
plaque. Even when excess
plaque is reasonably removed-
 The only modification in
this technique is we add
Maxicure sealants A and B.
This sealant contains
hydrofluoric acid in its
monomer thereby preventing
caries
 5. Adhesive precoated
brackets
JCO-1993-March by Ronald B Cooper.
Except for the
APC brackets the rest of the procedure is similar
Laboratory research and clinical trials did not reveal
significant differences in failure rates between
precoated and noncoated elements
6. Sondhi indirect
adhesive AJO-April-
1999
A new resin with higher
viscosity [fine particle fumed
silica filler] Setting
time-30 sec
Complete curing in 2 min
SPECIAL ARTICLE Efficient and
effective indirect bonding Anoop
Sondhi, DDS, MS* Indianapolis, (Am J
Orthod Dentofacial Orthop 1999
 A new method for effective and efficient indirect
bonding of orthodontic brackets has been
presented. The custom adhesive bases are easily
formed with Transbond XT on APC brackets, and
the indirect bonding is accomplished with a new
resin developed specifically for this purpose.
Bond strength has proven to be excellent, and
used this system for the indirect bonding of
complete dental arches, from second molar to
second molar, on pediatric, adult, and
orthognathic cases
 . The viscosity has been increased with the use of
a fine particle fumed silica filler (approximately
5%), so that any small imperfections in the
custom base crafted from the light-cured
adhesive, as well as any imperfections in the fit
of the custom base against the enamel, will be
taken up by the filled resin. An unfilled resin, on
the other hand, would be less viscous and could
cause bracket drift. Further, the resin has a quick
set time of 30 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
 The lab procedure
Working models in orthodontic stone,
prepared from accurate alginate
impressions, are necessary. Care
should be taken to ensure that there is
no distortion of the impressions.
Separating medium should be applied
-1 hour and dry it
 APC brackets-removed directly from the
sealed blister
 If non coated brackets-Transbond XT light
cured adhesive-placed on mesh pad
 Remove the excess cement.
Cure the resin
Significant undercut areas are
blocked with wax.
Bonding trays are formed-either
double tray technique or with
silicone transfer material.
 The indirect bonding trays can now be placed
over the brackets. A Biostar unit to vaccum
form a 1 mm thick layer of Bioplast,
overlayered with a 1 mm thick layer of Biocryl
is used.
 The bonding tray’s hard outer shell should be
trimmed away from all heights of contour for
patient comfort and closer fit because it only
permits firm seating of the soft tray.
 The bonding trays are now removed from the models
and may have to be sectioned off with a bur. It may be
necessary to tease the tray off with a scaler. Any excess
material should be trimmed with scissors or a scalpel.
Once the bonding trays have been trimmed, they
should be placed in the TRIAD unit for an additional
minute to ensure that any uncured resin is cured.
 The trays should now be cleaned in an ultrasonic cleaner
with a dishwashing detergent for 10 minutes,
  The trays are then run through the ultrasonic, in water
only, for an additional 5 minutes. They are then rinsed
and dried thoroughly
The bonding procedure-
 . Initial preparations
 Pumice all teeth. Explain to the patient that this
is one of several procedures
 2. Rinse and suction well with water.
 3. Show the bonding trays to the patient and
explain the procedure for bonding
 4.If there are bands to fit, this should be
completed after the indirect bonding procedure
has been completed,or whether the tray needs
to be sectioned into two segments is a decision
based primarily on the degree of isolation that is
feasible
 . Isolate the teeth that are to be bonded with plastic cheek retractors,
Tongue Away, and cotton rolls
 Using air syringe, dry teeth thoroughly.
  Etching solution is applied onto the teeth and kept for 15 seconds.
 . After 15 seconds, rinse with a steady stream of water for 15 sec
 Rinse with a steady spray of water and air for another 30 seconds.
Suction excess water and be careful that saliva does30 seconds.
  Replace cotton rolls again making sure that saliva does not contact the
etched enamel.
 The etched teeth should have a frosty appearance and be completely
desiccated. If a frosty appearance is not apparent, repeat the etching
process for 15 seconds.
Small amounts of the
indirect bonding Resin A
and B liquids (Sondhi
rapid set) should be
poured into the wells
Resin A can be painted
onto the tooth surface
with a brush,
Resin B can be painted
on the resin pads in the
indirect bonding tray
Position the tray over the teeth and seat the tray with a hinge motion.
With the fingers, apply equal pressure to the occlusal, labial, and buccal
surfaces. Hold for a minimum of 30 seconds. Allow 2 more minutes of
cure time before removing the tray. This procedure is now repeated for
the opposing arch. Because of the rapid set time of this adhesive, by the
time the opposing tray is placed, removal of the first tray can begin
Remove Tray with scaler- from lingual to buccal
 Main indication of IB-
lingual
Early 1970s – Dr Craven Kurz – Assistant
Professor of occlusion and gnathology

Plastic lee fischer brackets –ant. and metal for

posterior
Disadvantage of
Shear force -debonding
Uncomfortable to the tongue
Situations where lingual
therapy is advantageous -
1. Intrusion.
2. Max arch expansion .
3. Max molar distalisation
 Intrusion
Brackets closer to c res.
Intrusive forces closer to c res.
Bite plane effect – active
intrusion on ant and passive
extrusion of post
 Maxillary arch expansion
although not clearly
understood,clinically…
possible reasons--
1. Centrifugal force
2. Thickness of brackets
3. Shorter IB span could
also be a possible cause
Maxillary molar
distalisation. Lingual
attachments are closer to the c
res.of the molar – which is found
corresponding to the palatal root
of molar
 There are 7 genertions of brackets with
modifications

The bases now modified as -incisally and

mesio distally wide
Additionally gingival hooks were
redesigned so that they are shorter and
also away from the gingiva
Laboratory techniques.
1. CLASS system.
2. TARG system.
3. HIRO system.
Advantages
Permits more accurate
placement of brackets
Decreases chair side time
Less patient discomfort
Esthetically more pleasing
Incidence of caries is less
 Avoiding band fitting on
posterior teeth
 Improved ability to bond
posterior teeth
Disadvantages
Technique sensitive
Additional set of
impressions needed
Posterior attachments
more likely to fail if the
patient chews
Removal of adhesive is more
difficult and time consuming
Risk for adhesive deficiencies is
greater
Failure rates seems to be slightly
higher
 Extensive laboratory work
required
 Risk of debonding is high
The 21st Century—

. Time for Digital Technology The 21st century is

the age of modern digital technologies in
orthodontic practice. To improve precision of
bracket placement, several computer-aided
solutions have been proposed. A new approach,
presented in 2006, connects the indirect bonding
method with CAD/CAM technology . The
method, described as rapid prototyping, is used
to prepare precisely designed transfer trays. At
first, the traditional impression with the silicon
base material is taken
 The obtained model is then scanned with a high
resolution 3D scanner to achieve a digital record.
The corresponding software enables clinicians to
design the bracket placement virtually with great
accuracy (0.1 mm). Next, the 3D individual
transfers—the rapid prototyping trays (RPT) for
each tooth—are printed. In the following step,
braces are fixed intraorally.
 Teeth are prepared according to adhesive
bonding guidelines: etching with 37%
orthophosphoric acid, rinsing, drying and
applying a thin layer of primer.
 The bases of orthodontic brackets are
covered with the adhesive material and then
inserted carefully in their determined location
in Trays. The trays with brackets are placed
on the teeth and after the light-induced
polymerization process the transfer (RPT) is
removed, while brackets remained attached
to the enamel surface
 The accuracy of CAD/CAM-aided bracket
placement has been questioned . When
traditional gypsum casts are compared with
computer imaging, the digital technique is
considered less precise in mapping the tips of
dental cusps. From an orthodontic point of view,
the tip of the dental cusp is an important point of
reference for determining the bracket position.
Attrited teeth with shorter cusps revealed more
errors in digital projection . However, the
research proved that
 more inaccuracies may occur compared with the
traditional technique, these minor deficiencies
can be eliminated with dedicated software and
virtual set-ups it confirmed that CAD/CAM
technology provides accurate bracket
placement in laboratory conditions
 . Koo et al. found that, on average, IDB was
more accurate regarding bracket height, with
no significant difference between IDB and
direct bonding for angulation and mesiodistal
position.(Am J Orthod Dentofacial Orthop.
1999)
2020
Digital orthodontic indirect bonding systems: A new wave
Nasib Balut1,   APOS Trends Orthod 2020

 (a) Location of the coronal-root axis, first upper molar,

(b) position of the coronal-root axis, upper cuspid, (c)
location of the coronal-root axis, upper central incisor.
 (a) Position of the brackets in the model, upper incisors
frontal view, (b) position of the brackets, lower incisors
frontal view, (c) occlusal view of the brackets, position in
the upper arch, (d) occlusal view of the brackets, position
in the lower arch using the Ortho-Analyzer Software
Accuracy of bracket positions with a CAD/CAM
indirect bonding system in posterior teeth with
different cusp heightsJiyeon Kim - Am J Orthod
Dentofacial Orthop 2018

 .
 Five kinds of maxillary arch models, without attrition,
were divided into 2 groups: control group (with 0.5 mm
of grinding) and experimental group (with the addition of
0.5 mm of wax to the cusp tip). Rapid prototype models
were printed for both groups.
 A difference in cusp height of maxillary
posterior teeth did not produce a statistically
significant difference in the linear and angular
dimensions of bracket placement with the
CAD/CAM indirect bonding system. However,
given the tendency for a higher frequency in
bracket placement errors in posterior teeth
with larger cusp tips, cusp height should be
considered when using a CAD/CAM indirect
bonding system.
In vitro evaluation of shear bond
strengths and in vivo analysis of bond
survival of indirect-bonding resins
 1-
Omur
   Polat Angle Orthod
. 2004
 For the in vitro study, 60 extracted premolars were
divided into three groups. In indirect group I, the
brackets were bonded to models using Therma
Cure laboratory resin and transferred to the teeth
using Custom IQ resin for indirect bonding.
 For indirect group II, the teeth were attached to
models using Transbond XT and transferred using
Sondhi Rapid Set. In the direct-bonding group,
 .
  There were no significant differences between
indirect group I and direct group (P > .05),
whereas both yielded significantly higher SBS
values compared with indirect group II. In vivo
bond survival evaluation showed no differences
between the two indirect-bonding systems
available.
  Effect of adhesion boosters on indirect bracket
bonding 
Lylian Kazumi Kanashiro  et al
Angle Orthod (2014
 Sixty bovine incisors were randomly divided
into three groups brackets were indirectly
bonded using only Sondhi adhesive. In groups
2 and 3, the adhesion boosters Enhance
Adhesion Booster and Assure Universal
Bonding Resin, respectively, were applied
before bonding with Sondhi.
 In vitro shear bond strength was acceptable
in all groups. The use of the Assure adhesion
booster significantly increased both the shear
bond strength of indirectly bonded brackets
and the amount of adhesive that remained on
the enamel after bracket debonding.
Indirect vs direct bonding of mandibular fixed retainers
in orthodontic patients: A single-center randomized
controlled trial comparing placement time and failure
over a 6-month period
Efstathia Bovali –ajo-do 2014
 The objective of this 2-arm parallel single-
center trial was to compare placement time
and numbers of failures of mandibular lingual
retainers bonded with
 Sixty-four patients were randomized in a 1:1
direct procedure vs a direct bonding procedure.
 Indirect bonding was statistically significantly
faster than direct bonding, with both
techniques showing similar risks of failure
Indirect vs direct bonding of mandibular fixed retainers
in orthodontic patients: Comparison of retainer failures
and posttreatment stability. A 2-year follow-up of a
single-center randomized controlled trial
Fabienne Egli- ajo-do 2016
 Lingual mandibular retainers bonded with direct and indirect
methods were assessed.
 •Two years after bonding, risks of failure did not differ.
 •Bonded lingual retainers maintained intercanine and interpremolar
distances.
 •Fewer unexpected changes occurred with the indirect method
compared with the direct.
 •Severe unexpected changes were observed in 1 patient of 60
(1.6%).-  systematically consisting in a lingual inclination of the
mandibular left canine, were observed. In 1 patient (3%), the change
was considered clinically severe. No other serious harm was
observed.
 Conclusion when
the laboratory and the clinical
procedures are strongly
adhered,indirect bonding is
undoubtedly a valuable technique. It
proves itself by saving chair side
time which is the most valuable for
a practitioner.
 Digital technology in progressing by
leaps and bounds in field of
orthodontics. One can use this
technology in many different ways
with sole purpose being simplifying it
toward quality orthodontic care for
the patients
If not for the labial technique,it
is definitely a boon for the
lingual operating system
.
Thank you 
 REFERENCES

 William R Proffit,Contemporary orthodontics

Third Edition,2002
 Thomas M Graber, Robert L, Vanarsdall,
Orthodontics :Current Principles and Technique
Fourth Edition,2003
 Robert E Moyers Handbook of orthodontics
Fourth Edition,
 Kharbanda.Diagnosis and Management of
Malocclusion and Dentofacial
deformities.Mosby,elsevier,2001
 Silverman, E.; Cohen, M.; Gianelly, A.A.;
Dietz, V.S. A universal direct bonding system
for both metal and plastic brackets. Am. J.
Orthod. 1972, 62, 236–244.
 2. Newman, G.V. Epoxy adhesives for
orthodontic attachments: Progress report.
Am. J. Orthod. Dentofac. Orthop. 1965,
 L.J. Shear bond strength comparison
between direct and indirect bonded
orthodontic brackets. Am. J. Orthod.
Dentofac. Orthop. 2003,.
 4. Thomas, R.G. Indirect bonding: Simplicity
in action. J. Clin. Orthod. JCO 1979,