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
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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
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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
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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.
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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
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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
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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.
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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
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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
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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.
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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
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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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