Bond Reliably

8/3/2019 Bond Reliably

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BOND RELIABLY !!

DIFFICULT AREAS........ EASY SOLUTIONS !!

Bonding is an integral part of an Orthodontic treatment; but itssimplicity can be misleading.

One of the most frustrating experiences in an Orthodontic

office is debonding of brackets ; their reasons being multifactorial. It can

be either due to faulty bonding procedures employed by the Orthodontist

or faulty food habits by the patients. Yet another reason are the clinical

conditions which make placing brackets very difficult.

As time has evolved, Orthodontics has widened its horizonsand more and adults are undergoing this treatment. As much as we are

promoting the ‘Interdisciplinary Approach’, wherein the orthodontist uses

adjunctive procedures to enhance the overall treatment plan, the

difficulties regarding the bonding procedures are increasing.

Some of these challenging conditions include bonding on

impacted, partially erupted, ectopically positioned, severely rotated and

fluorosed teeth, cross bite, deep bite cases, various restorations, prosthesis,

wet field bondings, Lingual Orthodontic procedures and Adjunctive

procedures in adults using Interdisciplinary approach.

Hereby some different ways to bond these difficult surfaces

will be discussed which are an inhibition to an Orthodontist yet routinely

encountered, thus saving on chairside time and achieving low bond

failure rates.

I. ATYPICAL SURFACE BONDING :

a) FLUOROSED TEETH :

High incidence of fluorosis is seen in Northern India.

Bonding brackets to fluorosed teeth remains a notable clinical

challenge because of frequent bracket failure at the compromised enamel

interface. Fluorosed enamel demonstrates an outer hypermineralized and



acid-resistant layer, where it is difficult to attach bonds because a reliable

etched enamel surface cannot be produced.

Fluorosed teeth

This led to micromechanical etching of fluorosed enamel by

microabrasion before etching but it has its own drawbacks.

An alternative method of bonding to fluorosed teeth is use of an

adhesion promoter. It consists of a primer which is an aqueous solution

of hydroxyethyl methacrylate (HEMA) and polyalkenoic acid whic is thought

to assist moisture control. Primer allows subsequent resin layer to flow or

wet the etched surface.

Scotchbond Multipurpose Plus Primer – 3M



Adhesive is Bis-GMA and HEMA resin combined with blend of

amines which can provide a fast 10 second cure when activated by

visible light curing unit.

This chemical adhesion to enamel is said to have lessmicroleakage and superior hermetic seal.

PROCEDURE :

Teeth are polished with pumice and water slurry.

27% phosphoric acid placed on enamel with syringe applicator for

30 seconds.

Etchant then washed with water for 10 seconds followed by air

drying for 10 seconds with air. Adhesion promoter - Scotchbond Multipurpose Plus Primer – 3M

applied and gently air dried for 5 seconds followed by curing for

10 seconds. The brackets with sealant placed on tooth and light cured.

b) PORCELAIN AND METAL CROWNS :

As more and more adults seek orthodontic treatment

clinicians are faced with challenge of bonding to porcelain

restortations ( crowns, veneers ) and metal restorations.

Porcelain Crowns Metal Crowns



This requires following a detailed procedure and using

both safe and effective bonding materials, resulting in a reliable bond

that does not compromise integrity and porcelain surface.

Two options are available when bonding to porcelain –

1. Bond it mechanically by etching porcelain with hydrofluoric acid.

2. Bond it chemically using silane coupling agent.

Porcelain Primer

The disadvantages of hydrofluoric acid are that it creates porous,

roughened surface in porcelain much like etched enamel and removes

outerglaze which is extremely difficult to regain after treatment.

Thus silane coupling agent, in the form of porcelain primer, to

obtain chemical bonds are preferred even though it involves

meticulous procedure.

PROCEDURE :

Obtain isolation and saliva control for porcelain crown to be

bonded.

Apply liquid phosphoric acid solution to the glazed porcelain

surface.

Do not rinse off the acid!!

In presence of acid - apply porcelain primer solution to

porcelain surface using fresh cotton pellet. Apply second coat of primer.



Leave combined solution of primer and etchant for 1 minute.

After 1 minute thoroughly rinse and dry porcelain.

Apply sealant to prepared porcelain surface.

Then apply bracket with bonding paste according to

manufacturers instructions.

For a metal or stainless steel crown –

Sandblast metal surface to be bonded.

Rinse thoroughly and dry.

Paint a thin coat of a metal primer like for eg. Reliance Metal

Primer on the crown.

Then apply a sealant / resin on conditioned metal surface.

Bond the attachment with any light, chemical or dual cure adhesive

paste.

Metal Primer

II. WET FIELD BONDINGS :

Moisture contamination after etching is the primary cause of early

bond failure and is an inherent problem all orthodontists face on a daily

basis. In adults due to poor oral hygiene, gingival bleeding is encountered



during bonding procedures when sometimes done immediately after scaling.

Also bonding becomes difficult in excessively salivating patients.

Bonding hard to reach areas like impacted canines, second molars

and lingual bondings are extremely technique sensitive due to moisturecontamination.

TransbondTM

Moisture Insensitive Primer by 3M Unitek is an

ethanol based priming agent which can be used in such wet field

bondings. The technique used is the same as conventional acid etching

technique, however less emphasis is placed on completely drying the teeth

prior to applying Transbond MIP. This enhances speed and efficiency of

bonding procedure.

TransbondTM Multipurpose Primer

TransbondTM

MIP that can be used with light cure resins such as

Adhesive Coating System and TransbondXT

Adhesive as well as chemically

cured ConciseTM

Adhessive and UniteTM

Adhesive.

Even Self etching primers like the one by 3M i.e TransbondTM

Plus SEP performs equally well in either wet or dry environment. The

SEP’s are applied without the need to be rinsed unlike the conventional



etchants. Post application of self etching primer surface is air dried as

these products contain solvents such as water, ethanol and acetone.

TransbondTM Plus Self Etching Primer

During bonding procedures in excessively salivating patients,

antisialogogues like pilocarpine can be used. They are usually placed under

the tongue.

III. ATYPICAL TOOTH ANATOMY AND TOOTH

POSITION :

Bonding on teeth with atypical anatomy and

compromised position in the arch is very challenging situation.

A narrow or unerrupted teeth does not provide with enough surface

area for bonding as seen in peg laterals and partially erupted teeth.On crowded / rotated teeth bonding becomes challenging as enough

tooth is not exposed or there is interference with adjacent bracket or

tooth.

In all such cases a multipurpose attachment by Dr. Nikhil

Vashi can be used. In partially erupted teeth they can be bonded to the

occlusal surface until it is brought into alignment.



Multipurpose Attachment

Usually a Niti wire is in place which can get deflected tosome extent and the tooth gets derotated over a period of time due to

2 point contact of ligature tie on the main arch wire.

The advantages of MPA apart from it being easier to bond

include minimal occlusal interference, minimal trauma to oral tissues as

it is thin, helps in reducing treatment time as it can be bonded earlier

than a regular bracket where bonding a regular bracket in correct

position is difficult or uncomfortable for patient.

Crowding Rotation



Peg Laterl Small Clinical Crowns

Attachment bonded on the tooth by keeping lumen incisal if

there is no occlusal interference with opposing tooth as otherwise there

are chances of lumen getting crushed or flattened with occlusal

interference. In such cases lumen can be kept gingival and attachment

can be bonded as incisal / occlusal as possible. The height of

attachment can also be reduced.

IV. IMPACTED CANINE :

The highest incidence of impacted teeth faced by an Orthodontist

are the canines. Closed erruption technique requires traction which can

be done using amalgam pins which tend to damage enamel.

A new bonded attachment called U-flex erruption device can also

be used. The base is U shaped and flexible to fit snugly to the most

curved portion of the tooth i.e the incisal edge.

U-Flex Erruption Device Composite Placement



It is low profile to reduce risk of dehiscence of overlying soft

tissue flap. It is coated with titanium nitride to prevent allergic reactions.

The first link of the chain is round so that it can be attached

from any angle. Sequential reduction of links can be done as the tooth

errupts. Active ligation of the chain is done 4 months post surgically.

A light cured composite is placed on the mesh base, slightly

excess should be left on the base and positioned as desired and pressed

to express excess composite. Do not remove the flash or further adjust

the base as any movement can lead to bond failure.

U-Fex Placed On Crown Tip

V. BITE INTERFERENCES :

Deep Bite

In deep bite cases bonding difficult because of occlusal

interference. So bite blocks are given which can be anterior or posterior

and fixed or removable.

Removable bite planes require patient co-operation, produces

mucosal trauma and sometimes infection in case of oral hygiene

maintenance.



The bite ramp by GAC is very useful orthodontic device to

correct deep bite and curve of spee and helps in bonding of mandibular

incisor early in treatment and thus decreases the treatment time.

Bite Ramp – GAC

Advantages of it being no necessity to be built, easy to bond

and hygienic.

In lingual orthodontics fixed bite planes are fixed to orthodontic

bands on upper 1st

molars and can be constructed in the office by glass

ionomer cement, composite or self cured acrylic resin. Accidental

debonding of bite planes is rare because occlusal forces are moderated

by proprioceptive reflex and most pressure is directed against the toothsurface.

Posterior bite planes are usually given on functional cusps and

can be done by glass ionomer cement or composite.

Posterior Bite Block



Thus the evolution in bonding materials and the procedures have

simplified bonding in otherwise compromised tooth surfaces and play a

key role in success of modern orthodontics.

REFERENCES :

1. In vivo bonding of orthodontic brackets to fluorosed enamel using

an adhesion promoter. – James Noble, Nicholas E. Karaiskos,

William A. Wiltshire. – AO, Vol78,No.2,2008.2. Reliable Porcelain bonding. – Michael l. Swartz – Orthodontic Cyber

Journal. – Feb 2004.

3. Bonding to porcelain and gold. – David P. Wood, Ronald E. Jordan.

– AJODO March 1986 Vol 89 No. 3

4. Reliance Orthodontic products – Orthodontic bonding technique

manual - Paul Gange

5. Wet Field Bonding in the 21st

Century – by Robert A. Miller.

6. Multipurpose Attachment – Braces India Orthodontic Products7. A New Erruption Attachment for Impacted Teeth. – R.H.A Sameuls

– JCO 2004 Vol 38 No.9

8. Use of Bite Ramp in Orthodontic Treatment – Leonardo Tavares

Camardella, Elvira Gomes Camardella, Guilherme Janson – A.A.O

Scientific Posterboards.

9. Bonded Acrylic lingual Biteplanes. – Ronald Madsen – JCO – Online

1998 Vol 35, No.5 (311-317).





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