BONDING ORTHODONTIC BRACKETS I.

Introduction:
Palmer notation used in Orthodontics Right 2n
d

1s
t

2nd B 5 4 29 5

1st B 4 5 28 4

Cu

LI

CI

CI

LI

Cu

1st B 4 12 21 4

2nd B 5 13 20 5

1st M 6 14 19 6

2nd M 7 15 18 7

Left

M Upper Tooth # 7 2

M 6 3 3 0 6 3 6 27 3 2 7 26 2 1 8 25 1 1 9 24 1 2 10 23 2 3 11 22 3 Upper

Tooth 3 # 1 Lower 7

Lower

The bracket height chart is written in Palmer Notation (Figure 1A). This notation numbers the teeth starting with the central incisors as 1. The laterals are then 2. The canines are 3. The 1st and 2nd premolars are 4 and 5 respectively, the 1st molars are 6 and the 2nd molars are 7. Figure 1A. Bracket Heights from Cusp tip or Incisal Edge

Right
Upper Brack et heigh t Occ plane Brack e t heigh t

2n
d

1st M 6

2n
d

1st B 4

C u 3 4. 5

LI

CI

CI

LI

Cu

1st B 4

2nd B 5

1st M 6

2nd M 7

Left

M 7

B 5 2 1 1 2 3 4. 5 3. 5 Uppe r In mm

4 3 3. 5 3. 5 3. 5

4 3. 5

4 3. 5 3

4 4. 5

4 4. 5

3. 5

3. 5

In mm

Lower

Lowe r

II. Laboratory Exercise:

Step 1: Place Columbia typodont with complete dentition on pole to simulate a clinical situation.

Step 2: Pick up a bracket with the cotton pliers as shown in above figure. It is advisable to begin with the maxillary central incisor, for this exercise.

Step 3: Place a small dab of white rope wax on back of bracket as shown in above figure. The wax is being used as a substitute for the composite bonding material that would be used for an actual patient. Step 4: Place the bracket in center of the facial surface of the appropriate tooth and press firmly to express the excess wax. Step 5: Using a perio probe or a boone gauge (if your instructor has one) measure the height of the bracket from the incisal edge of the tooth to the center of the bracket. For example, horizontal slot of the bracket for the maxillary central incisor should be 4mm from its incisal edge. Step 6: Idealize the bracket position mesio-distally and occluso-gingivally (refer to appropriate figure in following pages for tooth specific instructions). Step 7: Continue with remaining brackets until all have been placed on the appropriate teeth. Evaluate vertical position of each bracket in relation to the incisal edge of the tooth where it is placed, then evaluate the vertical position of

each bracket in relation to the adjacent brackets. Evaluate the mesiodistal position of each bracket. Ask your GTA or faculty to evaluate your bracket positioning.

Bracket Positioning: General Instructions

Dimple or paint dot identifies disto-gingival

Center each bracket on the crown long-axis Vertical slot between the bracket wings parallel to the CROWN LONG AXIS!!! Posterior teeth the center of the bracket slot at the height of convexity Bicuspids - the archwire slot is lined up parallel to a line connecting the mesial and distal crest of convexity (proximal contact pts.). This corresponds to the (occluso-gingival) center of a normally fully erupted clinical crown. There are many different systems for bracketing teeth. Recommended bracket height will vary depending on manufacturer and system. Mesio-distal positioning is often best viewed in a mirror similar to checking a crown prep for parallelism.

Maxillary Teeth
Upper Central Incisors Distance from the slot to the incisal edge = 4mm From the occlusal, the bracket is centered mesio-distally. The bracket position usually appears somewhat incisal. As a guide, approximate the incisal edge of the tooth with the base of the bracket, perpendicular to the clinical crown long axis. 4

Upper Lateral Incisor Distance from the slot to the incisal edge = 3.5mm The incisal edges of the maxillary laterals will line up on the same level or slightly gingival to the central incisors. This is one-half to one millimeter shorter than the maxillary cuspid tip. From the occlusal, the bracket is centered mesio-distally. 3. On a fully 5 erupted lateral, the correct vertical position for the bracket is usually slightly more incisal relative to the center of the clinical crown Future restorative plan for malformed laterals should be factored into bracket placement As a guide, approximate the incisal edge with the slot to align the archwire slot perpendicular to the clinical crown long axis.

Upper Cuspids Distance from cusp tip to bracket slot = 4.5 mm The severe angulation and prominent anatomy of cuspids (10o) can make placement difficult From the occlusal view, the bracket is centered mesio-distally on the prominent buccal developmental ridge. This also corresponds to the clinical crown long 4.5 axis. This will usually be mesial to the center of the contacts Sharp cusp tips on newly erupted canines may need to be modified

Upper Bicuspids Distance from cusp tip to bracket slot = 4 mm Upper bicuspid bracket placement is the most difficult due to individual variability in tooth morphology. Often the brackets are not placed gingivally enough, especially on smaller sized or partially erupted teeth, resulting in a vertical step between the 1st molar and the 2nd bicuspid. From the occlusal view, the bracket is centered mesiodistally on the prominent buccal developmental ridge. This also corresponds to the clinical crown long axis. Thus, the archwire slot is lined up with the maximum convexities mesio-distally and occlusogingivally on the

crown.

Mandibular Teeth
Lower Incisors Distance from incisal edge = 4mm From the occlusal, the brackets are centered mesiodistally. Position the archwire slots so that the incisal edges of the incisors will be one half to one millimeter shorter gingivally than the cuspid tip after initial alignment. With the incisal edge and the base of the bracket as a guide, align bracket wings parallel to the clinical crown long axis and the base of the bracket perpendicular to the crown long axis.

Lower cuspid Distance from cusp tip = 4.5 mm From an occlusal view, the bracket is centered mesiodistally on the prominent buccal developmental ridge. This corresponds also to the clinical crown long axis. Like the upper cuspid this is mesial to the center of the contacts The archwire slot is lined up parallel to an imaginary line passing through the mesial and distal proximal contact points. This bracket height will vary depending on the size of the other teeth, and the size and shape of the cuspid and its cusp tip. Press firmly, checking carefully that a vertical line through the bracket wings is parallel with the clinical crown long axis.

Lower bicuspids

Distance from cusp tip to bracket slot = 4 mm Centered mesio-distally Bracket slot parallels the marginal ridges and contacts If a partially erupted 2nd bicuspid is bracketed too far occlusally the marginal ridges will be inferior to adjacent teeth after leveling Direct vision of the facial surface is important to properly positioning the bracket relative to the marginal ridges

Positioning Errors
The most important factor in aligning teeth using contemporary orthodontic techniques is precise bracket positioning. Proper bracket position is critical if our treatment objectives are to be achieved with the preadjusted bracket (straight wire appliance). Correct initial placement of the preadjusted brackets should minimize iatrogenic complications. The correction of bracket placement errors tends to be extrusive. Since orthodontic extrusion of teeth is the easiest movement, one can assume that the lowest bracket (tooth ) will come up to the level of the highest adjacent bracket. Each subsequent re-bracketing may tend to raise the entire occlusal plane.

III. Clinical Procedure A. Band Positioning: General Instructions Maxillary first molar bands
A) POSITION a) Select a size by using the diagnostic model b) If the initial band is not the right size then choose a band 3 sizes larger or smaller and then work toward the correct size

c) Seat the distal of the band first, firmly using a band seater or bite stick to utilize biting force. d) Seat the band in the patient's mouth until the archwire slot is located in the middle of the clinical crown occluso-gingivally e) Excessive seating of the band will cause extrusion f) A small band insufficiently seated will position the buccal tube too far occlusally g) Uneven seating on the buccal relative to the lingual will lead to torque errors, height of the cusps above the band should be equivalent h) Uneven seating on the mesial relative to the distal will lead to tip errors, the band should fit just below the marginal ridges i) From the occlusal view, the entrance of the mesial of the buccal tube should line up with the mesio-buccal cusp tip. As the band is seated, the slot is to be horizontal and level in relation to the crown. Mesial and distal marginal ridges indicate height and level. B) ADAPTING BAND AFTER SEATING a) Once the appropriate band size has been selected, adapt the metal margins of the band with a plugger or Hauk file. b) Both right and left bands should be checked to make sure they are in the same vertical position on the crowns.

Mandibular first molar bands

A) POSITION a) From the occlusal, the mesial of the buccal tube lines up with the mesio-buccal cusp tip. b) Seat the lingual first with most of the seating done on the buccal and the mesio-buccal. c) Seat until the archwire slot is located in the middle of the clinical crown occlusogingivally. d) The slot is approximately horizontal and level in relation to the crown. The buccal cusps can be used as a guide as well as the marginal ridges.

B)

ADAPTATION Adapt well with a band pusher, especially between the distal and the distobuccal cusps. Bend over any excess band material above the occlusal and

marginal ridges and trim excess away with a stone. A fully seated band should fit just below the marginal ridges with no excess to trim off.

B. Direct Bonding:
Surface of the Teeth

Bonding of Brackets Directly on the Facial Direct bonding technique can yield good bracket placement with minimum chair time and no laboratory time. 1. All of the teeth are cleaned using a prophy angle with a mixture of fine flour of pumice and water. 2. The teeth are then isolated with a cheek retractor and good saliva evacuation is performed. The teeth are washed and dried with air water spray. Maintain a dry field and keep the tongue out of the way. 3. To prepare the teeth for bonding, the facial surface of each tooth is etched with phosphoric acid for 30 seconds. Wash and dry all teeth thoroughly as for restorative procedures. 4. The teeth are desicated to expose a chalky or frosted appearance, indicating an adequate etch has been achieved. 5. The facial surface of each tooth is sealed with an unfilled resin (or

sealant) and light cured for 5 10 seconds. 6. It is advisable to begin bonding in the mandibular arch, as it is the most susceptible to saliva contamination. Bonding material is mixed (if necessary) and applied to each individual bracket by the assistant 7. Cotton pliers or special bracket placing instruments are used to transfer the bracket from the bracket set up to the tooth. The doctor places the bracket carefully using firm pressure to express excess material, removes the excess material and idealizes mesio-distal and inciso-gingival bracket placement. 8. The recommended sequence is: lower left and then right bicuspids, cuspids and incisors, working from side to side to insure that the heights are even on both sides of the mouth. Then the upper bicuspids, cuspids and finally the incisors again working from side to side (e.g. left second bicuspid, right second bicuspid, left first bicuspid, right first bicuspid and so on). Bracket adjustment is done with an instrument that will fit into the archwire slot of the bracket and allow manipulation of the bracket.

IV. Supplemental information on the direct bonding technique

Introduction: In 1955 Buonocore wrote a paper entitled, A Simple Method of Increasing the Adhesion of Acrylic filling Materials to Enamel Surfaces. He is quoted as saying, " In an attempt to obtain bonding between filling material and tooth structure, the alteration of the tooth surface by chemical treatment to produce a new surface to which acrylic filling material might adhere must be explored." This very statement laid the foundation for contemporary bonding techniques. Interestingly enough, this concept was borrowed from the use of preparations containing phosphoric acid in industry to prepare metal surfaces for better adhesion of paint and resin coatings. Buonocore researched the preceding technique by using phosphoric acid ( 85%! ) to etch the surface to help acrylic adhere to human teeth for considerable lengths of time ( avg. 1070 hrs.). His study brought to light these important factors concerning etched tooth enamel: a) the acid etching action creates a tremendous increase in surface area available for bonding b) the exposure of the organic framework of the enamel serves as a network, in and about which the acrylic can adhere c) old fully reacted and inert enamel surface is removed d) a fresh, reactive surface more favorable for adhesion is exposed. However, his clinical methods and observations did not take into account the importance of removing the accumulated organic plaque on the surfaces of the teeth before etching. Theoretical Considerations: With the advent of better materials (i.e. orthodontic brackets, isolation devices, bonding systems etc.), the contemporary techniques of orthodontic bonding have greatly improved. Certain principles must be clearly understood regardless of the new materials and techniques. 1) Prophylaxis: A thorough prophylaxis with wet pumice or oil-free and non-fluoridated prophy paste of the tooth surface to be bonded is imperative. Plaque removal from the enamel surface increases the wettability of the surface (Figure 1). The greater the wettability the greater the tendency for a fluid to spread over the enamel surface and the lesser the tendency for a fluid to bead on the surface. Care is taken not to agitate gingival tissue during the cleaning procedure to prevent bleeding on the enamel surface to be bonded. After cleaning the enamel surface it is

thoroughly rinsed with water (Figure 2), isolated if needed, and dried (moisture and oil free air). The success of the next phase of orthodontic bonding technique is totally dependent on proper prophylaxis to increase the wettability of the surface.

2)

Etching: After prophylaxis the tooth surfaces are ready for etching. The principle of etching is to simply remove microscopic amounts of enamel leaving porosities. This creates an increase in surface area and an architecture favorable for microretention. There are two types of etching media, liquid and gel. Liquid is applied by saturating a small sponge pellet with acid and carrying it to the enamel surface (Figure 3). The time for the etching solution (35% to 65% phosphoric acid) to remain on the enamel, is approximately 30 seconds. Etching gel is applied to the tooth with a syringe and remains on the surface for 20 30 seconds. The surface is rinsed with water for approximately one minute and thoroughly dried. The final etched surface will have a white chalky appearance (Figure 4). Etching should be done carefully (avoid contact with the gingiva and oral mucosa) and in accordance with the manufacturer's instructions. This step is one of the most critical factors in successful bonding. Improper etching and moisture control are probably the major causes of failure in bonding. There are a few precautions to consider during etching. Rubbing the etchant on the surface of the enamel must be avoided since pressure will break newly exposed enamel rods. The liquid etchant solution should be replenished every 10 to 15 seconds to avoid partial evaporation and a more viscous solution, this is not required with the gel. Salivary contamination of the newly etched enamel will greatly reduce the eventual bond strength. Isolation and maintenance of a dry uncontaminated field is critical. Operator induced complications include oil and water contamination from the air hose to the air syringe. Check the air hose tubing routinely by blowing air on a gauze pad or paper tissue which will reveal oil and water particles. Minimizing the previously mentioned complications, is the KEY to successful orthodontic bonding.

3)

Use of adhesives: The bonding adhesives used to adhere orthodontic bracket to enamel have improved tremendously over the years. During the middle 1970's different brands of bonding adhesives strong enough for routine clinical use became commercially available to the orthodontist. Clinical research led to contemporary bonding adhesives that exhibit these qualities: a) a coefficient of expansion relative to enamel with minimal water absorption b) development of full adhesive strength in a relatively short period of time so arch wire placement can be accomplished in the same visit c) long enough working time to allow the orthodontist to properly position the bracket d) no toxic effects e) stain resistant

It is important to prevent the bonding system (i.e. etching solution, sealants, and pastes) from touching the marginal gingiva during application to the tooth surface. The etchant may chemically burn the gingiva and cured adhesive near the gingiva will encourage plaque accumulation. Running an explorer along the gingiva after bonding will detect the thin transparent sealant that tends to form there. The bonding systems for placement of orthodontic brackets, are of two types: chemical cure or light cure. The chemical cure can be either; a) one step (no mix) or b) two steps. The one step involves no mixing of the bonding adhesives. The polymerization catalyst (liquid) is painted on the back (mesh) side of the bracket pad and the etched enamel surface. The bonding adhesive or paste is placed on the back (mesh) side of the bracket pad in an unpolymerized form. When the bracket is placed on the tooth surface; the paste polymerizes. The unpolymerized paste around the margins can be easily cleaned away. The two step system is the most common and consists of polymers and catalysts. It usually requires the mixing of a sealant and paste to accomplish adherence of the bracket to the tooth. The sealant is mixed (two liquids) and applied to the etched enamel surface to prevent microleakage and to wet the surface. (Figure 5). The paste is mixed (usually two components) vigorously for approximately 20 seconds and applied to the back of the bracket pad (Figure 6). The bracket is placed in the proper position on the prepared tooth (Figure 7). Once the paste on the mixing pad begins to polymerize, do not move or reposition the bracket. At that moment, start a new mix for the next bracket placement. Arch wires can usually be inserted approximately five minutes after the placement of the final bracket. The light cure adhesive is placed similar to restorative composites. The etched surface is coated with a light cured sealant. Then the adhesive is dispensed directly on to the bracket base and pressed to place. After positioning the bracket is tacked into place with a quick 5-second cure that prevents drifting while the other brackets are placed. After all brackets are positioned the full cure of 40 seconds is applied to each tooth. The advantage of the light cure system is nearly unlimited positioning time References: Buonocore, M. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J. Dent. Res. 34: 849, 1955 Sheykholeslam, Z. and Brandt, S. Some factors affecting the bonding of orthodontic attachments to tooth surfaces. J. Clin. Orthod. 11: 734, 1977 Brandt, S. Servoss, J. and Wolfson, J. Practical methods of bonding direct and indirect. J. Clin. Orthod. 9: 610, 1975 Profitt, W. Contemporary Orthodontics, The C.V. Mosby Company, 1986