SPECIAL ARTICLE
Efficient and effective indirect bonding
Anoop Sondhi, DDS, MS*
Indianapolis, Ind
A new resin designed specifically for indirect bonding has been developed. Previous problems with indirect
bonding systems, which were partly related to the fact that resins designed for direct bonding had to be
used, have been addressed. A cohesive and complete system for fabricating bonding trays, and the indirect
bonding procedure, is presented. (Am J Orthod Dentofacial Orthop 1999;115:352-9)
It has been widely recognized for many
years that accurate bracket positioning is of critical
importance in the efficient application of biomechanics
and in realizing the full potential of a preadjusted edge-
wise appliance. The same principle that governs real
estate is applicable to bracket positioning—Location!
Location!! Location!!!
BRACKET POSITIONING AND DIRECT BONDING
The advent of direct bonding improved the clini-
cian’s ability to position the brackets more accurately
than when using bands. The introduction of light-cured
resins like Transbond XT Light Cure Adhesive (Trans-
bond, 3M/Unitek, Monrovia, Calif) further improved
the working time available to the clinician, permitting
significant latitude in positioning the brackets before the
resin is cured. However, achieving an accurate and con-
sistent bracket position on the posterior teeth continues
to present a problem because of poor access. Rebonding
on posterior teeth isn’t any easier than bonding them the
first time, therefore the less bracket repositioning one
has to do on the posterior teeth, the better. On the ante-
rior teeth and the premolars, the cost of repositioning
the increasingly popular ceramic brackets is of concern.
This is less of an issue with indirect bonding.
BRACKET POSITIONING AND INDIRECT BONDING
Indirect bonding, in various forms, has been around
for several years.1-6 Most of these forms have been
variations on the technique originally proposed by
Thomas.1 Initially, we used candy to position the
brackets on the teeth, and chemically cured resins to
bond the brackets to the teeth. This generally resulted
in excessive flash, and clean-up was a significant prob-
lem. In addition, the laboratory time was excessively
*Research is supported in part by 3M/Unitek.
In private practice.
Reprint requests to: Anoop Sondhi, DDS, MS, 9333 N Meridian, Suite 301,
Indianapolis, IN 46260
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/97643
352
high. Different glues have been tried over the years, but
only with moderate success.
Heat-cured resins subsequently entered the market,
but several clinicians have experienced problems with
bracket float while heating the resin. This is aggravated by
the fact that the model must be heated to 350° for approx-
imately one half hour to cure the resin (Thermacure,
Reliance Orthodontic Products). Further, ceramic brack-
ets could not be exposed to such heat and had to be placed
separately after the metal brackets had been heat cured, a
cumbersome procedure. Current techniques for bonding
tray placement use chemically cured sealants or bonding
resins. However, if a transparent tray is used, light-cured
resin, with cure-on-demand benefits, can be used.7
RESIN DESIGN
This clinician has consistently used indirect bond-
ing in one form or another for the last 16 years. It
became clear that one of the deficiencies in the avail-
able systems is that all the resins and procedures had
originally been designed for direct bonding, and subse-
quently were just adapted for indirect bonding.
For example, a desirable feature for a resin
designed for direct bonding is a generous window of
working time. In indirect bonding, once the tray is
placed there is clearly no use for an extended cure time.
After years of innovation, laboratory testing, and clini-
cal trials, a significantly superior, efficient, and effec-
tive indirect bonding procedure has been developed
utilizing a new resin specifically designed for indirect
bonding. An additional benefit of this procedure is that
it does not require heating the models, since a custom
base is developed with light-cured adhesive.
ADVANTAGES OF INDIRECT BONDING
Obviously, there are some significant advantages to
indirect bonding1-7:
1. Accurate bracket placement
2. Optimizing the use of doctor’s time
3. Avoiding band fitting on posterior teeth
4. Eliminating the need for separators
American Journal of Orthodontics and Dentofacial Orthopedics Sondhi 353
Volume 115, Number 4

A
A

B
B

C
Fig 1. Anterior (A) and occlusal (B) views of maxillary
working models for indirect bonding. C, application of
separating medium.
5. Improved ability to bond posterior teeth
6. Improved patient comfort and hygiene
DISADVANTAGES OF INDIRECT BONDING
1. Technique sensitive
2. Additional set of impressions needed
3. Posterior attachments more likely to fail if
patient chews ice, etc.
A NEW INDIRECT BONDING MATERIAL
Having recognized the clinician’s need for bonding
materials designed specifically for indirect bonding, a
C
Fig 2. A, Placement of APC brackets on the working
model; B, lateral view of working model shows individual
bracket positions; C, models ready to be checked; mod-
els are kept in a black box to keep out ambient light.
new resin has been developed with the help of 3M
Unitek. This material is designed with several objectives
in mind. 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 imperfec-
tions 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
354 Sondhi American Journal of Orthodontics and Dentofacial Orthopedics
April 1999

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

seconds, which significantly decreases the time needed to

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

CUSTOM BASE WITH LIGHT-CURED ADHESIVE

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

A D

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

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

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

A A

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

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

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

A A

B B

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

proper bracket placement and the doctor’s input

on appliance design to the patient.
5. If there are bands to fit, this should be completed
after the indirect bonding procedure has been
completed. Because this indirect bonding resin
has such a fast set time, the band fitting can be
started immediately. D
Patient Bonding
Fig 9. Indirect bonded appliance: A, anterior view; B, lat-
1. Whether the indirect bonding procedure can be eral view; C, maxillary occlusal view; D, mandibular
completed with a single tray for the entire arch or occlusal view.
358 Sondhi
2.
A fine aluminum oxide particle (50 µm) is recom-
3.
4.
5.
B 6.
7.
C excess water and be careful that saliva does not
Fig 10. Bar graph shows (A) bond strength 24 hours 8.
after bracket placement; indirect adhesive compares
favorably with Concise and Transbond; B, bond strength
9.
5 minutes after bracket placement; these data are of crit-
ical importance because the immediate bond strength is
important during tray removal and initial arch wire inser-
tion; and C, bond strength development over 24 hours.
whether the tray needs to be sectioned into two
segments is a decision based primarily on the
degree of isolation that is feasible. If there is sig-
nificant crowding and imbrication of the teeth, it
may be easier to section the tray. Since the work-
ing time with the indirect bonding resin is virtu-
ally unlimited (because the adhesive does not
American Journal of Orthodontics and Dentofacial Orthopedics
April 1999
need to be mixed), the degree of isolation and
ease of tray placement are the determining fac-
tors. On rare occasions, it may be advisable to
consider sectioning the tray into thirds, in which
case the trays may be sectioned as follows:
6-11 or 27-22 (anterior segment)
2-5 or 12-15: 31-28 or 21-18 (posterior segment)
Examine the trays carefully for any remaining sep-
arator or tray material covering the adhesive cus-
tom base on the bracket. Use a micro-etching unit
to lightly sandblast the adhesive custom bases. A
mended. Take care not to abrade the resin base.
If there is any contamination of the adhesive cus-
tom bases, especially if you touch them with
your fingertips, apply acetone to adhesive bases
and air dry them.
Isolate the teeth that are to be bonded with the
NOLA (Nola Specialties, Hilton Head, SC) dry-
field system. Occasionally, if necessary, plastic
cheek retractors, Tongue Away (TP Orthodon-
tics), cotton rolls, and Dri-Angles (Young Dental,
Earth City, Mo) may be used (Fig 6A).
Using air syringe, dry teeth thoroughly.
Dab—do not rub—etching solution onto teeth
and set stop-watch for 30 seconds. (Note: Etch-
ing solution should be applied with extreme
care. Do not allow etch to contact skin or gin-
giva.) The etch should be applied in the general
area that is to be covered by the bracket. Do not
allow the etch to flow into the interproximal con-
tacts. The clean up will go much more smoothly
if this is kept in mind.
After 30 seconds, rinse with a steady stream of
water for 15 seconds. Rinse with a steady spray
of water and air for another 30 seconds. Suction
come into contact with the etched enamel.
Replace cotton rolls and Dri-Angles, again making
sure that saliva does not contact the etched enamel.
A. If the clinician chooses to use Transbond MIP
Moisture Insensitive Primer on the enamel surface
before the indirect bonding procedure, then the air
syringe should be used to remove excess moisture.
Complete desiccation of the teeth is optional (Fig
16B). A liberal coat of Transbond MIP should be
painted onto the enamel surface. Air dry for
approximately 3 to 5 seconds. Light curing of this
product is not necessary for indirect bonding.
B.If Transbond MIP Moisture Insensitive Primer
is not used, and the bonding is accomplished with
the indirect bonding resin, then all visible mois-
ture should be removed. The etched teeth should
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 115, Number 4
have a frosty appearance and be completely des-
iccated. If a frosty appearance is not apparent,
repeat the etching process for 15 seconds.
10. Small amounts of the indirect bonding Resin A
and B liquids should be poured into the wells (Fig
7A). Take care to keep liquids separate. Resin A
can be painted onto the tooth surface with a brush,
and Resin B can be painted on the resin pads in
the indirect bonding tray (Fig 7B and C)
11. If too much resin has been placed on the enamel,
gently remove the excess with a brush. The over-
all method of painting the resin on the enamel
and the custom bases is not unlike painting one’s
fingernails.
12. Position the tray over the teeth and seat the tray with
a hinge motion. With the fingers, apply equal pres-
sure 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 (Fig
8A). This procedure is now repeated for the oppos-
ing arch (Fig 8B). Because of the rapid set time of
this adhesive, by the time the opposing tray is
placed, removal of the first tray can begin (Fig 8C).
Fig 9A-D show the completed appliance placement.
13. Remove the tray by using a scaler to peel the tray
from the lingual to buccal. Use extreme care
when removing the tray from around bracket
wings. Scale the excess resin around the brackets
and from the interproximal contacts. Use dental
floss to check that all contacts are open.
14. An initial arch wire, such as an 0.016 Nitinol
Heat-Activated Wire can now be inserted.
RESULTS
In treating over 500 patients, our experience with
this indirect bonding adhesive has revealed that the
bonding is relatively consistent and efficient. Occa-
sional bond failures do occur, of course, and are usually
related to contamination or improper technique. In
those cases, it is a simple matter to section the bonding
tray, reapply the adhesive, and reseat the brackets.
Bond strength tests have also proved the efficacy of
this resin. The graph illustrated in Fig 10A shows that
bond strength compares favorably with indirect bond-
ing using Concise Enamel Bond and Custom IQ. Bond
Sondhi 359
strength is demonstrated in pounds per bracket, and a
total of 25 brackets were tested. Fig 10B provides more
important data, since the bond strength immediately
after curing is of critical importance during tray
removal, and initial arch wire insertion. In that test, our
indirect resin showed substantially greater bond
strength than the other resins. After 1 hour, the other
resins started to catch up (Fig 10C). Eventually, the
bond strength of all three materials peaked to relatively
similar levels. However, the clinical efficacy of this
resin is greatly enhanced by the higher bond strength
when tested at the 5 minute level. Indirect bonding
with Concise Enamel Bond has a distinct disadvantage,
of course, because of the limited working time, longer
cure time, and the need to mix the resin. As has been
pointed out earlier in this article, this is because Con-
cise Enamel Bond was developed specifically for direct
bonding, and the Sondhi Indirect Adhesive has been
developed specifically for indirect bonding.
DISCUSSION
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 accom-
plished with a new resin developed specifically for this
purpose. Bond strength has proven to be excellent, and
we have used this system for the indirect bonding of
complete dental arches, from second molar to second
molar, on pediatric, adult, and orthognathic cases.
I gratefully acknowledge the contribution of Mr Darrell
James of 3M/Unitek in the development of the resin reported
in this article. The assistance provided by Mr Steve Fletcher,
Ms Rani Stoddard, and Mr John Lamitie in the preparation of
this article is also gratefully acknowledged.
References
1. Thomas R. Indirect bonding: simplicity in action. J Clin Orthod 1979;13:93-106.
2. Moin K, Dogon IL. Indirect bonding of orthodontic attachments. Am J Orthod
1977;72:261-75.
3. Simmons M. Improved laboratory procedure for indirect bonding of attachments. J
Clin Orthod 1978;12:300-2.
4. Silverman E, Cohen M. A report on major improvement in the indirect bonding of
attachments. J Clin Orthod 1975;9:270-6.
5. Scholz R. Indirect bonding revisited. J Clin Orthod 1983;17:529-36.
6. Moskowitz EM, Knight LD, Sheridan JJ, Esmay T, Kruno T. A new look at indirect
bonding. J Clin Orthod 1996;5:277-81.
7. Kasrovi P, Timmins S, Shen A. A new approach to indirect bonding using light-cure
composites. Am J Orthod Dentofacial Orthop 1997;6:652-66.