BONDING-I / Orthodontic Courses by Indian Dental Academy

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BONDING IN ORTHODONTICS
II
INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

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CONTENTS
1. Evolution of bonding agents
2. Banding
3. Indirect bonding
4. Bonding to special surfaces
5. Bond strength
6. Debonding
7. Decalcification and
demineralization
8. Hazards of bonding

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EVOLUTION OF BONDING MATERIALS
An appliance which
cannot be made
transparent or tooth-
colored should at least be
made smaller.
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Schanges adjustable clamp band Angles retraction screw
1871 - W.E. MAGILL Zinc oxycloride
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Laborious, time-consuming, skill
Partially erupted teeth
Decalcification /discoloration
Gingival irritation
Unaesthetic
Need of separators
Closure of band spaces What you see is not
what you get

6 www.indiandentalacademy.com
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3 major developments that made bonding of
attachments to teeth possible

1. BUONOCORE 1955 improved retention of
methyl methacrylate to enamel 85% phosphoric
acid for 30 seconds

2. BOWEN 1962 bis Glycidyl methacrylate
more stable and greater strength

3. NEWMAN 1965 first to acid etch and bond
orthodontic brackets with epoxy resin

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Orthodontic attachments had to be cemented on
teeth instead of the intermediary bands-

Methylmethacrylate monomer MMA first
material to be used
Catalyst Benzoyl peroxide BPO
Powder-liquid system
In use in restorative dentistry
Poor adhesion - Polymerization shrinkage
Pulpal irritation

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BUONOCORE (1955)

Improved retention of methyl methacrylate to
enamel 85% phosphoric acid for 30 seconds

Not successful for orthodontic purposes

Occlusal force
Wide range of oral thermal change
Wet environment

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G. V. NEWMAN (1965)
Bonded plastic brackets with epoxy resins
Start of direct bonding procedure
For short-term treatment with anterior brackets
Did not replace metal-band system

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First commercially available orthodontic adhesives

1. OIS Adhesive system OIS company in 1969
2. Bracket Bond GAC in 1970

MMA -BPO-amine catalyst system
Weak Adhesion
Early 70s - all adhesives consisted of MMA - it
bonded chemically to plastic brackets in vogue

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Fujio Miura and associates in 1971

Introduced ORTHOMITE
MMA - TriNButyl Borane (catalyst)
Increased adhesive strength
Coupling agent silane
methacryloxypropyltrimethoxysilane
Increased adhesive penetration
Chemically bonded to adhesive
Affinity to enamel

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Merits of MMA adhesives:

1. Plastic brackets
2. Good storage stability
3. Increased working time brush-on / dip-in
4. Elimination of sealant - good penetration into
enamel surface
5. Less damage during debonding

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Demerits of MMA adhesives:

1. Fluctuating proportion of powder-liquid
depending on operator

2. Poor mechanical interlocking to metal bracket
bases
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Metal brackets enter the scene

Plastic worry about enamel-adhesive
Enamel-adhesive & adhesive-bracket

Adhesive-bracket -Mesh, perforated pad , foil mesh
Enamel-adhesive
Increased hardness of adhesive
MMA BisGMA
Filler material - TEGDMA

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Bisphenol Glycidyl Dimethacrylate (Bis-GMA)

BOWEN 1962
Greater strength
Lower water absorption
Less polymerization shrinkage
2-paste system
Strongest adhesives for metal brackets
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FILLERS:
Reduce viscosity of resin
Reduce polymerization shrinkage
Quartz, silica glass particles
3 - 20 microns - abrasion resistance
0.2 0.3 microns - smooth surface - less plaque
retention
Adhesives with large particle fillers recommended for extra
bond strength, but careful removal of excess is mandatory

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Di/triethyl glycol dimethacrylate (TEGDMA)
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Merit and demerit of Bis-GMA hardness

Poor penetration due to increased viscosity
dilute with MMA
Plastic brackets could not be used primer for
partially dissolving added
Active life less than powder liquid system

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In 1974 ORTHOMITE II 20% more
HNPM
hydroxynapthoxypropylmethacrylate
Eliminated silane

4 - META methacryloxyethyl trimellitate
anhydride
ORTHOMITE SUPER BOND

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4 - META

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

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Orthodontic adhesives are variations of-
Adhesives
Direct-restorative materials used in
restorative dentistry

Late 20
th
century direct restorative biomaterials
1. Resin-matrix originated in U.S.
2. Salt-matrix U.K.
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1. RESIN MATRIX:
Classification -

According to organic matrix components -
A. Acrylic resins MMA Ex. ORTHOMITE, GENIE
B. Diacrylate resins- BisGMA Ex.CONCISE, PHASE II

According to polymerisation mechanism
A. Chemically activated
B. Light-cured
C. Dual-cured
D. Thermocured

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A. CHEMICALLY ACTIVATED:

Chemically-cured/ Auto-cured / Self-cured
Used since beginning of bonding
Most-widely used ortho adhesives
Two-paste / one-paste
Two-paste system:
Initiator- Benzyl peroxide in monomer
Activator- tertiary amine dihydroxyethyl p-
toluidine

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Ex. Concise (3M)

Good bond strength

Laborious
Time-consuming
Increased air-exposure- oxygen inhibition
Defects air entrapment, voids
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One-paste system:

One adhesive component applied to bracket base
and other on tooth surface catalyst gradient
No-mixing
Bracket positioned accurately - pressed firmly
into place
Curing occurs 30-60 secs
Ex. Rely-a-bond, System 1+, Unite

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Procedure simplified
Fast
Efficient

Little long term information available on bond
strength
Inhomogeneous polymerisation sandwich
technique
Enamel and bracket side more polymerized
Liquid activators toxic, allergic reactions
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B. LIGHT-CURED:

Visible-light cured
Camphoroquinone
Cure from incisal and gingival areas
Increased working time
Ideal for educational purpose
DC same as Chemical-cure; same for metal
and ceramic brackets
Photocuring time-consuming

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C. DUAL-CURED:

Intiation exposure to light
Propagation chemically cured
Advantages of light and chemically cured
Improved surface and bulk material properties
Highest DC, bond strength
Ideal for bonding molar tubes

Most time-consuming
Bulk defect due to mixing

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D. THERMO-CURED:

Exposure to heat

Superior properties

Not for direct but only indirect bonding
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Adhesives acting in the presence of water

1. MOISTURE-RESISTANT
- can bond in presence of water
- saliva, gingival fluid contaminants
- ex. Transbond MIP
2. MOISTURE-ACTIVE
- need water for bonding
- enamel surface intentionally made wet
- Cyanoacrylate no liquid, only paste
- ex. Smartbond

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CYANOACRYLATES:

Ethyl-cyanoacrylate Smartbond-orthodontic
bracket adhesive (1991)
Other uses
Automobiles,Circuit boards,Light aircraft
Fracture fixation
Skin sutures
Cardiac surgery
Guided tissue regeneration

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Crabb and Wilson 1971- compared with
polycarboxylate cement poor
performance and bond strength,
unsuitable for clinical use
Howells and Jones 1994 poor
performance on storage in saline for a
week
Krishnan et al 1994 equal to Bis-GMA
when kept in 37
o
C for 24 hours

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THOMAS W. - JCO 2000 - Compared the shear
bond strength and debonding effects of Smart-
Bond & Rely-a-bond
Smart-Bonds strength was significantly
higher
No danger of fracturing the enamel
Polycarbonate bracket - work only if they
are pretreated with water
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Ideal characteristics of Bonding medium:

1. Non-toxic
2. Adequate working and setting time
3. Moderate viscosity
4. Ability to wet etched surface
5. Sufficient tensile and compressive strength -
retain bracket & ease of debonding
6. Resist decomposition in the oral environment
7. Antimicrobial

36
Evaluation of antimicrobial properties of
orthodontic composite resin combined with
benzalkonium chloride

Othman et al,AJO Sep2002

The antimicrobial agent benzalkonium chloride
added to a chemically cured composite resin
Anti microbial benefits and bond strength of the
modified composite were evaluated.

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Results:

No significant difference between the tensile
bond strength between modified composite and
the original product

The incorporated BAC added to anti microbial
properties of original composite without
altering its mechanical properties

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2. SALT MATRIX:
CEMENTS IN ORTHODONTICS:

Desirable properties:
1. Adequate working and setting time
2. High tensile, compressive and shear stress
3. Resistant to dissolution
4. Clinically acceptable bond strength
5. Low Adhesive Remnant Index (ARI) on
debonding
6. Anticariogenic potential
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ZINC PHOSPHATE:

Oldest of the luting cements
Powder and liquid system
Film thickness of 20 microns
Efficient mixing characteristics

Mechanical adhesion
Pulpal irritant - highly acidic
May cause decalcification of enamel resulting
in white spots

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ZINC SILICOPHOSPHATE:

Addition of silicate glass
Superior strength and fluoride releasing property

Extremely acidic
High solubility
No longer used
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ZINC POLYCARBOXYLATE CEMENT:

Introduced by Smith in 1968
First cement system that developed a chemical
bond to the tooth structure.
Early 70s Durelon poor bond strength
Combined desirable properties of Zn-
phosphate & ZOE

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Acid-base reaction

Chemical bond to tooth
Fluoride release
Shorter setting time
Viscous liquid less efficient mixing
characteristics - PSEUDOELASTIC
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GLASS IONOMER CEMENTS:

Developed and introduced in 1974 byWilson, Kent
and Smith.
To combine strength and fluoride release of
silicophosphate and adhesive efficiency of
carboxylate
Group of materials that use silicate glass powder
and an aqueous solution of Polyalkeonic acids

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Setting reaction:

Surface of glass particles is attacked by acid
Ca, Al, Na, Fl ions-leached into aqueous medium
Next 24 hours a new phase forms in which
aluminium ions become bound within the cement
matrix leading to a more rigid set cement
NaF uniformly dispersed in the set cement.
Unreacted portion of glass particles sheathed by
silica gel.
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Unreacted powder particles surrounded by a
silica gel in an amorphous matrix of hydrated
Ca++ and Al+++ polysalts.
During initial reaction if mix contaminated by
additional water or ambient air - dissolution of
matrix - weak and more soluble cement
Adhesion- chelation of carboxyl groups of
polyacids with Ca in apatite of enamel & dentin
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Biological properties :

Chemical adhesion
Bacteriostatic or bactericidal due to fluoride
release.
Acid - less irritating to the surrounding tissues
Enamel etching for luting bands not required
Reduces demineralization
Highest strength
Least solubility
Bonds to enamel and base metals

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Drawbacks:

Moisture sensitivity
Low early strength

Polymerizable resin functional groups added
Impart additional curing process
Allow the bulk of the material to mature
through the acid-base reaction.

RESIN MODIFIED GLASS IONOMER CEMENT
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Nicholson (Quint Int 1977)
Resin modified GICs are those materials that
are modified by the inclusion of resin, generally
to make them partly photocurable

W.M. Tay (Dental update 95)
These are hybrid materials that retain
significant acid base reaction as a part of their
overall curing process

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Advantages of RMGICs over GICs:

1. Sufficiently long working time controlled in
command to a snap set by photocuring.
2. Improved setting characteristics.
3. Protect the acid base balance from problem of
water balance.
4. Rapid development of early strength.
5. Fluoride release greater.
6. Diametral strength high (20 Mpa compared to 6. 6
Mpa)

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Disadvantages of RMGICs over GICs:

1. Biocompatibility is controversial.
2. Setting shrinkage is higher leading to
increased microleakage and poor marginal
adaptation
Brands
Fuji Ortho LC
Photacfil ESPE
Vitrebond 3M

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In 1986 White described a method of bonding
orthodontic brackets to the enamel surfaces of
teeth, with a glass ionomer cement.
Poor strength
Isolation of newly bonded teeth
Light arch-wires immediately after bonding

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

-Klockowski, Davis, Joynt, Wieczkowski, and
MacDo

Compared GICs (Ketac-fil, Ketac-cem and
Chelon) with Rely-A-Bond (no-mix
autopolymerising) which served as a standard
in a clinical study.

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Results:

Bond strength of GICs was significantly less
when compared to Rely-A-bond.
Less reduction of bond strength of GICs on
recycling lesser than Rely-A-bond on recycling
Failures involved cohesion within cement or
adhesion involving the enamel - easily scraped
off from the enamel surface without causing
much damage.

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Cook -1990 compared the in vivo bond
strength of a glass ionomer cement, Ketac
(ESPE Premier Denbol Products, Norristown,
Pa.), with a composite resin bonding agent
12% failure rate

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

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Fricker - 1994, worked with Fuji II LC glass
ionomer cement (GC Corp., Kyoto, Japan)
Same rate of success bonding brackets to
enamel surfaces as he did with composite
cements.
Dentine conditioner was utilized for ten
seconds

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Kusy - discussed the damage to teeth on
debonding after using composite bonding resins.
When is stronger better?
Use of glass ionomer cements for
orthodontic bonding procedures - do not
need etching or damage the enamel during
debonding.

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A new light-cured glass ionomer cement that bonds
brackets to teeth without etching in the presence of
saliva -AJO-DO SEP 1995
-Silverman, Cohen

Used a new Resin modified GIC
Fuji Ortho LC
Light-cured, resin-reinforced glass ionomer
cement
3 mechanisms of setting
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Advantages:

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

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Evaluation of fluoride release from an orthodontic
bonding system AJO-DO Aug 1991

-Samir E. Bishara, Edward J. Swift, Jr., Daniel C.
N. Chan,

Light-activated fluoride-releasing - FluorEver
OBA
Tensile bond strength was significantly less 1/3
1/2 of conventional (chan et al)

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Fluoride ion release 2.6ppm on day 1
0.42ppm on day 2
0.04ppm on day 43
However , decrease in enamel
decalcification was observed.

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BANDING
Feel the pinch
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Advantages of banding
Stronger
Protect against interproximal caries
Easier to recement and deband

1. CUSTOM-MADE
Indirect
Direct

2. PRE-FORMED

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1. CUSTOM-MADE BANDS:

1. Band-pinching
2. Band-cementation

1. BAND-PINCHING:
Food-trap for cariogenic debris
Exacting proximity between tooth and band
Poorly fitting band island in a sea of
cement.
BANDING PROCEDURE
67

BAND MATERIAL:

Precious metal
Chrome-cobalt alloy
Stainless steel
Size:

Thickness Width
Incisors 0.003 0.004 0.125
Premolars & Canines 0.004 0.150
Molars 0.005 0.006 0.180 0.200
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REQUIREMENTS:
1. Greatest strength and
durability with minimum of
bulk
2. Soft enough to permit close
adaptation
3. Strong enough to withstand
stresses
4. Polishable
5. Corrosion and tarnish resistant
6. Biocompatible
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2. BAND-CEMENTATION:
Do not depend on cement for retention
Drive fit

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Universal scaler parallel to band margin and
not perpendicular

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2. PRE-FORMED BANDS:

Band selection:
Casts
Variations anatomy, tapered crowns, extra
cusps, restorations
One size larger than the one that seems to fit
the tooth prevents wasteful distortion of
bands

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Band fitting:

First - finger pressure - only on mesial and distal
sides
Amalgam plugger / band pusher 2/3
rd

Bite pressure through biting stick facial and
lingual
Final seating pressure
Maxillary palatal side of tooth
Mandibular buccal side of tooth

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Checklist:

All cusps on banded teeth equally visible
Band margin
Just below marginal ridge
Above the contact point

Buccal attachment accurately positioned
Open occlusal margins crimped towards tooth
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