Bracket Placement

B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S 8 5
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6
6
Chapter
Bracket placement, bonding and

debonding techniques
David Birnie
8 6 B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S
Bracket placement
Theory of bracket siting and slot siting
Angulation landmarks
The five traditionally used landmarks are the facial axis of the crown, the long axis of the tooth, the incisal
edges, marginal ridges and contact points. Andrews feels that many of these landmarks are difficult to
observe or are too far from the bracket slot to be used as effective bracket siting guidelines.
Inclination landmarks
Inclination landmarks reported in the literature show bizarre variation. Tweed (1966) recommends that the
brackets should be placed a specified distance from the incisal edge. Saltzmann suggests that the
brackets should be placed in the middle third of the crown.
Holdaway (1952) suggests that the brackets be placed on the gingival third of the crown if there is an
anterior open bite, in the middle third of the crown if the overbite is normal and in the occlusal third of the
crown if there is an increased overbite. Jarabak uses crown form as a predictor as to where to place
brackets: in ovoid crowns the brackets should be placed in the middle third of the crown, in tapering crown
forms 1-2 mm from the incisal edge and in square crowns as close to the incisal edge as possible.
According to Andrews, slot inclination can vary by up to 45 degrees according to a bracket's site.
Using the Straight-Wire Appliance, accurate bracket siting is all that is required from the clinician. Once the
bracket is sited in its correct location, Andrews claims that the slot is automatically correctly positioned.
Characteristics of an ideal bracket site

The ideal bracket site is such that:
• a bracket located there will not interfere with the gingivae or opposing teeth during occlusion
• the angulation and inclination of the crown at the site will have a consistent angular
relationship to each tooth's occlusal surface and occlusal plane at all times
• the middle of each bracket site must share the same plane or surface when teeth are
optimally positioned.
The bracket siting method recommended by Andrews is therefore keyed to the occlusal plane, the facial
axis of the clinical crown and the facial axis point.
Slot siting
The faciolingual position of the slot is determined by the crown's prominence plane. This is the sum of the
molar prominence (1 mm) and the bracket stem prominence and is the same for all crowns in one arch.
The slot target point is the midpoint of the slot site for each tooth type. It is located at the junction of the
crown's prominence plane and the facial extensions of the crown's midsagittal and midtransverse planes.
Fowler (1990) looked at variations in ideal bracket location and concluded that the variability was greatest
for FACC angulation, then FA point height and finally for FA point mesiodistal location but that these
variations had few clinical implications.
SLOT SITING FE ATURES
• midtransverse plane of bracket slot, bracket stem and crown are coincident
• bracket base inclination
• occlusogingival base contour
• midsagittal plane of bracket slot, bracket stem and crown are coincident
• plane of bracket base at 90 degrees or 100 degrees (maxillary molars only)
• mesiodistal base contour
• parallel vertical bracket components

• equal stem prominence
SLOT SITING FE ATURES FOR TRANSL ATION BRACKETS
• counterrotation
• countermesiodistal tip
• counterbuccolingual tip (maxillary molars only)
The FACC and the FA point

The FACC (facial axis of the clinical crown) is for all teeth except for molars, the most prominent portion of
the central lobe on each crown's facial surface. On molars, the FACC is represented by the buccal groove
that separates the two mesial buccal cusps.
The FA (facial axis) point is the midpoint of the FACC.
In his textbook, Andrews has used the terms FACC and FA point to denote the facial axis of the clinical
crown and the facial axis point. These replace the older nomenclature LACC (long axis of the clinical
crown) and LA point (long axis point).
Andrews designed the Straight-Wire Appliance such that, in order to express the treatment built into the
bracket correctly, the base point of each bracket should be positioned over the FA point of the
corresponding tooth with the bracket aligned parallel to the FACC.
Advantages
The advantage of this method of positioning brackets is that it is simple, relatively accurate and requires no
special measuring device. It does result in the brackets being positioned slightly further gingivally than
normal and this helps to move the point of force application closer to the centre of resistance of the tooth.
Pitfalls
The disadvantage is that Andrew's method of bracket positioning does not take into account the fact that
the clinical crown is of variable length, particularly in adolescence and nor does it take account of abnormal
crown morphology such as obtuse incisal edge/FACC angles. In addition, it takes no account of biological
variability. For example, discrepancies often exist between the marginal ridges of premolars and molars;
these are not necessarily corrected by repositioning either the molar or the premolar tube or bracket as,
due to the curvature of the buccal surfaces, repositioning the tube or bracket may dramatically affect
torque. The only real solution here is to have vertical steps in the archwire to adjust the relative tube or
bracket positions to produce level marginal ridges and with the teeth at the correct torque.
Bracket placement studies

Fowler (1990) studied the variability both within and between clinicians in placing upper incisor and canine
brackets. The variability was greatest for FACC angulation, FA point height and FA point mesiodistal
location. Training and experience reduced variability and Fowler concluded that the clinical implications
were small.
Balut et al (1992) found similar findings with mean vertical variability of 0.34 mm and angular variability of
5.54 degrees. The teeth with greatest angular variation were the upper and lower canines and the upper
anterior teeth. The teeth with the greatest vertical variation were the upper second premolars.
Taylor and Cook (1992) also showed that angulation was the most variable factor but also that inclination
error frequently exceeded the 2° limit. This may be influenced by the variability in angulation.
Theoretical bracket placement charts

McLaughlin and Bennett (1995) have suggested the use of theoretical bracket placement charts.
McLaughlin and Bennett determined ideal bracket placement positions based on the midpoint of the clinical
crown using data on:
• anatomical crown heights

• clinical crown heights
• American Boards or Angle Society cases
• debonded cases that had settled into a good six keys occlusion
They found minor deviations of the centres of the clinical crowns on the:
• upper premolars
• the upper second molars
• lower canines
• lower first molars
From this data, a theoretical bracket placement chart was devised from which the user selects the row of
bracket heights which most closely corresponds to the half clinical crown height of the dentition to be
bonded. This is an interesting method that deserves further consideration and evaluation; it is however too
time consuming for everyday clinical use.
Recommended method of bracket placement

Bracket positioning remains as much an art as a science - perhaps more so. Bracket positioning should be
based on Andrew's method using the FA Point and the FACC. Upper incisors should be bonded so that
the incisal edges of the lateral and central incisors are at the same level; the lateral incisors may be
fractionally higher (up to 0.5 mm) but never longer.
Upper and lower canine tips should be slightly longer
0
than the adjacent teeth to facilitate canine guidance.
-1 In general aim to put the bracket in the centre of the
-2 clinical crown, but err on the side of placing it more
millimetres
-3
gingivally to keep the bracket:
-4
• closer to the centre of resistance of the
-5
tooth
-6
U1 U2 U3 U4 U5 U6 U7
• away from upper arch interferences (in
the lower arch)
Swain Alexander Bennett and McLaughlin
The following method is recommended:
6
For incisors and canines:
5
4 • check that clinical crown heights

millimetres
3 approximate to anatomical crown

2 heights
1 • check for abnormal incisal edge/FACC
angles
0
L1 L2 L3 L4 L5 L6 L7
For premolars and molars:
Swain Alexander Bennett and McLaughlin
• check location of FA point, cusp height
and marginal ridge height; aim to
Figure 6.1: Bracket placement in the upper and lower position bracket so as to get marginal
arches
ridges level
Then for all teeth:

• visualise FACC
• place bracket so that tiewings straddle FACC (or so that slot is parallel to incisal edge if
preferred)
• position base point on FA Point (or specified distance from incisal edge or cusp tip)
• seat bracket
o check placement
from facial surface
from occlusal surface with mirror
with contralateral side
relative to incisal edge
An excellent description of bracket positioning is given by Swain (1986). The bracket positioning chart
shown on page 90 can be used either at the start of treatment to select torques and make notations about
individual bracket positions or can be used in the last few months of treatment to identify tooth movement
required during the finishing phase.
Approximate measurements used by Swain (1986), Wick Alexander (1986) and McLaughlin and Bennett
(1995) from the slot point to the incisal edge are given in Figure 6.1. Careful attention should be paid to
looking at the morphology of each tooth and minor variations made in the position of each bracket to
ensure that optimal tooth positioning is obtained. In the case of incisor teeth with fractured edges, it is
better to try and establish a satisfactory bracket height from the contralateral tooth and then measure down
from the gingival margin for the damaged tooth.
On lower canines, it is worth positioning the bracket slightly mesially to ensure that the mesial edge of the
canine does not tuck behind that distal edge of the lateral incisor.
It is often difficult to get marginal ridges level; one tip is to align an imaginary line on the buccal surface of
the teeth, which joins the marginal ridges, and align the occlusal edge of the bracket with this line.
OrthoCAD bracket placement solution

The OrthoCAD bracket placement solution generates a computerised 3-D model from alginate impression
and a bite registration. A computerised setup is then completed and the pretreatment and post-treatment
3D simulations transmitted to the orthodontist. The orthodontist can, using local software, modify the
proposed setup if necessary. The OrthoCAD system is then used to position the brackets according to the
predetermined positions. The system consists of:
• a pen sized wand with

o miniature video camera
o dual purpose light for illumination and curing
o detachable curved tip for bracket positioning
• computer and monitor
Bracket placement is achieved by attaching a sleeve to the wand and placing the tip of the sleeve in the
bracket slot. The camera transmits real-time images of the patient’s teeth and can determine the position of
the wand relative to the selected tooth. A bracket-shaped target, matching the preselected bracket
position, is projected on the corresponding tooth on the video screen. The clinician matches the actual
bracket position to the target and then tacks the bracket in place. The suggested advantages of the
technique are:
• the effects of bracket positioning on the final result can be visualised before bracket
placement
• bracket positioning can be fine tuned

• bracket positioning can be carried out more easily by orthodontic therapists or chairside
operators
• it can be used for direct or indirect bonding
The technique is fully described by Redmond et al (2004).
Variations in use of brackets

Vertical position of brackets
The vertical positioning of brackets may be adjusted to facilitate treatment. Thus in deep bite cases the
brackets may be placed slightly occlusally and in open bite cases slightly gingivally on the incisors.
Incisors have relatively flat labial surfaces and so adjustments of vertical position have little if any effect on
torque. It should be remembered that these adjustments alter the distance between the centre of effort and
the centre of resistance of the tooth which will alter the tooth mechanics.
Vertical adjustment on teeth with curved buccal surfaces results in alteration of torque depending on how
curved the surface is and the extent of the vertical adjustment.
Over angulating brackets

Where teeth have to be translated a significant distance (such as in pseudotransposition cases) there is an
increased tendency to tip and so the brackets should be angulated to prevent this; this often requires a
significant over-angulation of the bracket. A similar situation occurs where implants are to be placed post
orthodontic treatment and the tooth roots must be parallel to one another to leave room for the implant.
Inverting brackets
Inverting a bracket changes its torque and rotation but not its in/out or tip. The brackets commonly inverted
are lateral incisors and canines. In general, inverting a bracket on its own rarely produces enough torque
to correct the problem one is trying to deal with and additional torque needs to be bent into the archwire to
optimise the final position of the tooth; that being the case, one might question if it is worth doing at all.
It is perhaps less advisable to use this technique with self-ligating brackets which are not symmetrical along
the slot axis unless one is happy to cope with an inverted slide or clip.
Inverting Roth prescription lateral incisor brackets changes their torque from +8° to -8° which is helpful
when moving a palatally placed lateral incisor into the line of the arch. Standard prescription brackets
change from +3° to -3° which is less useful.
If a decision is made to close an upper lateral incisor space then the upper canine brackets may be
inverted to produce palatal rather than buccal root torque. This is more relevant to the standard
prescription which has -7° of inclination in the maxillary canine in which case inverting produces a change
in torque of 14° whereas the Roth prescription has only -2° producing a change in inclination of only 4°
when inverted. In these cases the use of an inverted standard prescription canine bracket may harmonise
better with the central incisor root position than a Roth prescription bracket.
Most class 3 patients demonstrate considerable proclination of the upper labial segment at the end of
treatment. Although we have not tried it often, the use of labial root torque (achievable by inverting the
upper incisor brackets) with advancement of the upper labial segment is worth consideration. The case
published by Catania et al (1990) demonstrates significant maxillary development with only mild to
moderate proclination of the incisors using this technique.
Band or bond?
We use bonds increasingly frequently as technology improves. We routinely bond incisors, canines,
premolars and molars; banding molars is now a very, very rare event.
The reasons against bonding molars are as follows:
• the inferior quality of etch pattern obtained on molars

• the difficulty in obtaining and maintaining adequate moisture control during bonding
• inadequate adaptation of the attachment base thus producing an uneven adhesive layer
• the vertical bulk of molar tube designs with tiewings
• the larger masticatory forces found on the posterior regions of the mouth
Millett et al (1999) has published an excellent retrospective review of first molar bond failure. The median
survival time was 699 days and the overall failure rate was 21%. The tubes were placed with light-cured
Transbond. Age at the start of treatment (the older the better) and operator were significant factors in
determining bond failure rate, but patient’s gender or the presenting malocclusion was not.
A further study by Millett et al (2001) compared the shear bond strength of molar tubes bonded with either
a compomer (Ultra Band-Lok), a resin modified glass ionomer cement (3M Multi-Cure or Fiji Ortho LC and
a light cured resin adhesive (3M Unitek Transbond). Interestingly, the mean shear bond strength of tubes
bonded with 3M Transbond was significantly less than those bonded with 3M Multi-Cure or Fuji Ortho LC.
Ultra Band-Lok gave significantly lower shear bond strengths than Fuji Ortho LC. This suggests that
compomers or resin modified glass ionomer cements are viable alternatives to the use of a light cured resin
adhesive for bonding molar tubes.
We now bond all teeth including molars routinely unless bands are specifically required for the attachment
of a palatal or lingual intraoral auxiliary. The use of low profile bonding tubes, improved moisture control,
bond enhancers and improved adhesives make this an achievable goal.
Moisture control
Moisture control remains critical in the bonding process. It is still preferable to bond in a clean dry and
uncontaminated field. Steps to achieve this include:
• consider the use of an atropine sulphate tablet as suggested for indirect bonding. Although
not everybody will wish to do this, it does provide a very dry field which almost eliminates the
need for a saliva ejector, cotton wool rolls or Dri-Angles. The patient is given a 600
microgram tablet of atropine sulphate to take one hour before bonding as a TTO drug (to
take out) to dry up salivary secretions. (Contra-indications are: pregnancy, glaucoma, and
severe asthma. Wearers of contact lenses should be asked to remove them and not replace
them until the following day). Children under the age of 12 years are not given atropine.
• (optionally, use 4" braided cotton wool rolls to isolate the sulcus but not needed if bonding
small areas at a time)
• use a single ended photographic retractor to retract and isolate the working area
• isolate and bond a few teeth at a time; use a high speed light and get the nurse to cure each
bracket immediately after placement
• when bonding upper molars, ask the patient to move their mandible to the same side to carry
the soft tissues of the cheek away from the bonding site.
Figure 6.2: Bonding sequence. Use a single ended elliptical photographic retractor in areas 1 to 4 and a double ended retractor in
area 5
Bonding technique
As well as the atropine tablet, patients over the age of 12 years are given a 200 milligram ibuprofen tablet
to take one hour before the bonding appointment to reduce post-bonding discomfort. The bonding
sequence is as shown in Figure 6.2.
The orthodontist holds the retractor in one hand. Particularly when bonding upper second molars. It is
helpful to ask the patient to move the mandible to the same side as is being bonded to move the buccal
mucosa away from the buccal surface of the posterior teeth; a little experimentation with the position of the
retractor, the amount of mouth opening and the position of the mandible ensures a clear field for bonding.
The orthodontist etches and primes the enamel surface. The bonding pad with the brackets required for
the bond-up is placed on the bracket tray together with and adhesive pad and a tube of adhesive. The
orthodontist squeezes a small quantity of adhesive on to the adhesive pad, selects the bracket or tube to
be bonded and then smears a small quantity of adhesive paste on to the foil mesh base before positioning
the bracket or tube on the tooth surface. Once any excess is removed, the nurse then cures the adhesive
while the orthodontist selects and loads the next attachment. Brackets are picked up using a good quality
pair of College tweezers; these want to have fine, short and serrated tips; a small supply of newish
tweezers are kept for this purpose and replaced by new ones as they get worn when they can be used for
less delicate work.
Curing lights
The curing light market is developing rapidly. The following types of light are available:
• conventional curing lights

• high performance halogen curing lights (Optilux 501)
• plasma arc lights (PACs lights)
• lasers
• LEDs
A good summary of the various different types of light is given by Mayes (2000).
Light guides
Light guides collimate visible light to increase its intensity and thus reduce the curing time and increase the
depth of polymerisation (cure). Bishara et al (2001) investigated the effectiveness of light guides on the
shear bond strength of orthodontic brackets and found that when using a reduced cure time, the bond
strength of the brackets was significantly reduced.
However, Evans et al (2002) compared the effects of the Reliance Power Slot light guide and the Ormco
Turbo-Tip light guide with conventional curing lights. They found that the light guides significantly reduced
curing times by 10 seconds per bracket while maintaining the same bond strength. Light guides can be
retro-fitted to existing curing lights.
Conventional curing lights

Conventional curing lights use halogen bulbs filtered to produce blue light. They cure adhesive under
metal brackets in 20-30 seconds.
High performance halogen curing lights

The Demetron Optilux 501 is a high performance curing light with an 80-watt tungsten/quartz/halogen bulb
whose performance does not degrade with time. It cost about $1,500 or £800 in the year 2000. This has
an 8 mm light guide which emits a full spectrum light filtered as blue light with a range of 400 to 505
nanometres. It cures under metal brackets in 8 seconds and under ceramic brackets in 5 seconds. Bulb
replacement costs about £80.
The light has Boost mode which increases the light output to 1,000 mWatt/cm2 in 10 second cycles with a
five second beep. This allows adhesive under metal brackets to be cured with 5 second exposure in each
interdental space. The light is intense and at the tip of the guide, some discomfort on skin or mucosa may
occasionally be felt.
This light was the cutting edge of modern light technology and offered excellent performance/cost ratio.
The reduced time required to cure the adhesive significantly increases the attractiveness of a light cure
material compared to a dual cure. It has now been superseded by LED lights.
Plasma arc lights

These produce light by passing a high voltage through xenon plasma. The plasma bulb generates a lot of
heat and so a large fan is required. These lights produce limited spectrum light that is filtered to blue light
in the 400-490 nanometre range. They are not always easy to use as the wand cable is quite rigid and not
all models have hand controls although these are increasingly available. The lights cost about $3,500.
Adhesive is cured in 5 seconds under metal brackets and in three under ceramic brackets but the lights
have a refractory period before the light can be reactivated. The Apollo95E is an example of this type of
light.
Laser lights
These lights emit a monochromatic coherent light source in the blue light region of the visible spectrum
(457-502 nanometre range). They generate a lot of heat and are therefore somewhat cumbersome. Most
units are operate by a foot pedal and cost $6,000. An example is the LaserMed Accucure 3000. These
lights seem disproportionately expensive for the slightly greater reduction in curing time and are no longer a
serious curing light option.
LED lights
Quartz tungsten halogen lights have disadvantages:
• halogen bulbs have a life of about 50 hours

• the bulb, reflector and filter degrade

over time
• halogen bulbs generate significant
heat
Light emitting diodes (LEDs) have lifetimes of

10,000 hours and undergo little light degradation
during their life. In addition, no filters are required to
produce blue light, LEDs are robust and require little
power. Low power LEDs based on silicon carbide
technology have been available for many years but
their power output was only 7µW per LED which
was insufficient to cure dental resins. The
introduction of gallium-nitride technology in 1995
Figure 6.3: LE Demetron light with charger and metal saw the development of 3mW LEDs which
hydride battery represents a 400 times increase in power over the
former technology. The spectral output of these
blue LEDs falls within the absorption spectrum of
the camphorquinone photoinitiator (400nm to 500 nm) of dental composites (Mills et al 1999).
Parr and Rueggeberg (2002) (see Figure 6.1) have compared the spectral emission profiles of LEDs and
quartz tungsten halogen lights normalised for the absorption requirements of camphorquinone. They
concluded that while all LED lights produced lower power than quartz tungsten halogen lights, 80% of the
light produced by the LED lights met the needs of the camphorquinone photoinitiator whereas less than
70% of the light from the quartz halogen light did.
Fay et al (2002) looked at several of the mechanical properties of composite cured with LED and quartz
halogen lights and concluded that there was no statistical difference in the mechanical properties of
composites cured with either light. A similar conclusion was reached by Bishara et al (2003) who
compared the Ultradent UltraLume 2 with the 3M Unitek OrthoLux Visible Light Curing Unit. Mills et al
(1999) concluded that a significantly greater depth of cure was achieved using quartz halogen lights.
Bouschlicher et al (2002) looked at intrapulpal temperature rise during photoinitiation with LED, quartz
tungsten halogen and plasma arc lights. It was suggested that the narrow spectral emission of blue LED
light curing units would generate less heat than more conventional lights. They found that the LED, plasma
arc and newer quartz tungsten halogen lights (such as the Optilux 501) produced less intrapulpal
temperature rise than the older conventional quartz tungsten halogen lights.
Dunn and Taloumis (2002) compared the shear bond strength of orthodontic brackets bonded to teeth with
conventional halogen-based light-curing units and commercially available LED curing units. They studied
two LED lights (Lumalite LumaCure and Centrix VersaLux) and two halogen lights (Demetron Optilux 501
and Demetron ProLite). The study involved bonding orthodontic brackets with Transbond XT to extracted
third molar teeth and then measuring the sear bond strength of the brackets using an Instron testing
machine. No significant difference in bond strength was found between the four lights; the range of mean
bond strengths were from 8.8 to 8.5 MPa and the range of standard deviations from 1.0 to 1.2 MPa and so
neither the means nor the standard variations changed much between the groups. The curing time used
for each light was however 40 seconds.
Cacciafesta et al (2002) compared

Light Unit Peak λ (nm) Power Normalised Effectiveness
(mW) power (mW) (%) shear bond strengths produced with
Apollo 465 120 102 85 a high power halogen light (1,200
CoolBlu 465 68 85 85 mW/cm2) with the GC E-light (1,500
Lux-O-Max 469 52 42 82 mW/cm2). Using bovine teeth and
Optilux 501 478 409 277 68
Transbond XT adhesive, they found
Table 6.1: Comparison of quartz halogen curing light with three LED lights that the shear bond strength was no
demonstrating the relative effectiveness of LED lights (from Parr and Rueggeberg 2002) different between the LED and
halogen light groups using a 10 second curing time.
Mavropoulos et al (2005) have shown that the shear bond strengths achievable with the newer intensive
LED lights with a 10 second exposure is almost comparable with that achieved with high intensity halogen
lights with an exposure of 40 seconds.
We routinely use the new LEDemetron 1 (Figure 6.3) which produces an adequate depth of cure in 10
seconds; it works just as quickly as the Optilux 501, is silent, cordless and cures metal brackets with a 10
second cure. The LEDemetron 1 is unusual in having a single LED and a small noiseless fan; this reflects
the increasing power (and therefore increasing need for heat dissipation).
LED curing light technology has made enormous strides in just a few years and now challenges the well-
established halogen curing light. It is difficult to imagine why anyone would now want to buy the much
more expensive and bulky plasma arc or laser curing lights.
Curing technique
Wendl and Droschl (2004) investigated the effect of curing technique on the shear bond strength of
brackets using a light-cured resin (Enlight LV), a RMGIC (Fuji Ortho LC) and a chemically cured composite
(Concise) as a control. Four different types of light were used (halogen, high performance halogen, plasma
arc and LED) and two different types of curing (two sided and four sided). All lights produced adequate
bond strengths of 5 to 8 MPa. The bond strength of Enlight LV (but not Fuji Ortho LC) depended on the
duration of the light exposure with the highest bond strength being achieved with 40 second cure and the
halogen light. The bond strengths of the light cured adhesive and the resin modified glass ionomer
adhesive were similar although less than Concise. Four sided curing was better than two sided curing and
all adhesives had higher bond strengths after 24 hours than after one hour. For Enlight this was 19%, for
Fuji, 6.6% and for Concise 16%; the largest increase in bond strength occurred for the light cured
composite suggesting that the curing process continues once light exposure has ceased (dark cure).
Indirect bonding
Indirect bonding was originally described as an experimental technique by Silverman et al (1972). The
method involved applying mixed cement to each bracket in a transfer tray, a process requiring a slow
setting adhesive and subsequently necessitating flash removal of set adhesive.
Why indirect bonding?

The advantages of indirect bonding are:
• more accurate bracket and tube placement

• better use of the orthodontist’s time
• no need for separators; avoids band fitting on posterior teeth
• makes it easier to bond posterior teeth
• improved bond strength due to better moisture control and shorter bonding period
• improved patient comfort and hygiene
The disadvantages of indirect bonding are:
• it is technique sensitive
• an additional set of impressions is required
• bonded posterior attachments more vulnerable than bands
• may require the use of an anti-sialagogue
The development of indirect bonding

The following key stages can be identified in the development of indirect bonding:
• a significant advance was the Thomas technique, which used set composite on the bracket
bases (custom bases) which were then placed on the teeth using only a primer as the final
stage adhesive (Thomas 1979). This avoided the need to place composite on the bracket
bases immediately before tray insertion
• the introduction of a two tray system (Nakaji and Sheffield 1981), in Hickham J H, 1993).
This meant that the tray system could be sufficiently rigid to seat the brackets but sufficiently
flexible to allow easy removal of the transfer tray once the brackets had been placed on the
teeth and the adhesive had set. Using a Bioplast/Biocryl combination seems to work well
although Moskowitz et al (1996) have described using a vinyl polysiloxane (Caulk Reprosil)
impression material as the flexible undertray.
• the introduction of a no mix adhesive for the custom base that gives a consistent and
complete cure. This can be done using either a thermally cured adhesive, such as Reliance
Thermacure, (Sinha et al 1995) or a light-cured adhesive, such as 3M-Unitek APC brackets,
(Sondhi 1999). These techniques make it much easier for the orthodontists to position the
brackets on the models without the need for repeated mixing of adhesive. Conventional no
mix adhesives do not work well as an incomplete cure is obtained because the catalyst is
only applied to the bracket base.
• the introduction of custom indirect bonding adhesives for the final positioning of brackets on
the teeth, such as Reliance Custom IQ (Indirect Quickset) and 3M-Unitek Sondhi Rapid-Set.
These adhesives should be chemically cured and have a fairly short working time. Light cure
adhesives would seem to have little place at this stage of the indirect bonding process as
unlimited working time is not required.
Indirect bonding versus direct bonding

Accuracy of bracket placement
Two studies have looked at the accuracy of bracket placement comparing the two techniques - Aguirre et al
(1982) and Koo et al (1999). It is perhaps surprising that there have not been more studies. It would seem
that indirect bonding has a slight advantage but this is not as marked as perhaps would have been
expected; Aguirre found that vertical bracket position was more accurate with the indirect technique on
upper canines and more accurate on lower second premolars with the direct technique. Angular
positioning was very variable and more accurate on upper and lower canines with the indirect technique.
Koo found that indirect bonding was better in bracket height but that there was no difference in either
angulation or mesiodistal positioning between the two techniques.
Time utilisation
Aguirre et al (1982) looked at bonding second premolar to second premolar in the upper and lower dental
arches. They determined that the average time for direct bonding was 42 minutes and for indirect bonding
54 minutes for both laboratory and clinical phases. The clinical phase of indirect bonding took 24 minutes.
Kalange (1999) studied bonding second molar to second molar in the upper and lower arches and found
that the clinical phase of indirect bonding took 25 minutes and the laboratory phase 60 minutes.
Bond strength
In the early days of indirect bonding, prior to the introduction of the Thomas technique, Zachrisson and
Brobakken (1978) showed that direct bonding had a lower failure rate than indirect bonding. Using the
Thomas technique, however, Hocevar and Vincent (1988) showed that there was no difference in in vitro
bond strength between the indirect and direct bonding techniques. Aguirre et al (1982) had similar findings
with clinical failure rates of 4.5% for the indirect technique and 5.3% for the direct technique.
The Thomas technique introduced an interface not previously encountered in orthodontics - that of the
aged composite interface. Does the custom composite base, aged between set up and indirect bonding,
adhere as well as a conventional immediate mix adhesive? Shiau et al (1993) showed that an aged
composite interface up to seven days old was unlikely to affect bond strengths.
Technique
Clinical
1. Recontouring or restoration of teeth should be completed before bonding. Consider deferring
extractions or interproximal stripping until after bonding to prevent unwanted tooth movement.
2. Take a good alginate impression of the arch(es) to be bonded
3. Label the impression for indirect bonding
Laboratory
TECHNICIAN
1. Pour up the model in pure stone (not plaster or a plaster/stone mix)

2. Let the models dry completely
3. Coat the buccal surface of the working model with a 50:50 mix of liquid foil separator and
water and allow to dry overnight (or a minimum of 6 hours)
4. Deliver to clinician with brackets and tubes on a tray, adhesive, instruments and wipes ready
for bracket placement
CLINICIAN
1. Brush metal bracket bases with acetone or pure alcohol to degrease; on brackets with a
plastic base, apply one coat of Reliance Plastic Conditioner but no cleaning agent; on
ceramic brackets do not apply any cleaning agents or pre-conditioners
2. Place Reliance Phase II primer on bracket base(s)
3. Place Reliance Phase II chemical cure composite on the bracket base(s) and seat in ideal
position on the model
4. Clean off excess flash around each bracket as you place them
5. Allow brackets to cure for at least ten minutes at the end of the procedure
6. Request sectioning of tray as desired
TECHNICIAN
1. Suck down a 1.5 mm Bioplast sheet directly onto the cast to make the inner shell of the
indirect bonding tray
2. Coat the Bioplast tray with silicone spray separator
3. Suck down a 1.0 mm Splint Biocryl sheet onto the Bioplast to make the outer shell of the
indirect bonding tray
4. Once set, trim away any excess material with a knife and then soak in warm water for 15-20
minutes
5. Gently pry the tray away from the model
6. Brush the bracket bases again with either acetone or pure alcohol
7. Section the inner tray into quadrants or thirds as requested
8. Isolate in a sealed bag and label with the patient’s details
Clinical
1. If desired, give the patient a 600 microgram tablet of atropine sulphate 15-20 minutes before
bonding to dry up salivary secretions. (Contra-indications are: pregnancy, glaucoma, and
severe asthma. Wearers of contact lenses should be asked to remove them and not replace
them until the following day). Children under the age of 12 years are not given atropine.
2. Prepare the teeth for indirect bonding (polish, etch, isolate)
3. Do not trial seat the trays!
4. Paint a coat of Reliance Plastic Conditioner on the back of each bracket and allow to dry for
at least one minute
5. Using Reliance Custom IQ, paint sealant A on to the tooth surface and sealant B on to the
bracket base
6. Seat the soft inner shell quadrants first and then snap the hard shell over the top
7. Stabilise the tray by applying gentle pressure on the occlusal surfaces with your thumbs and
use all other fingers to apply pressure labially
8. After applying direct pressure for one minute, let the tray sit passively for a further four
minutes
9. After five minutes, peel the outer tray off first and then the inner tray quadrants from a palatal
or lingual direction, and working from front to back. Be careful to free each bracket in turn
completely and look for the easiest path of removal, particularly on combination tubes with
hooks. Tray removal may be facilitated by cutting the tray interproximally, occlusally or along
the line of the bracket slot.
10. Insert archwires and ligate
Debonding
The increase in effectiveness of bonding procedures and the advances in bonding technology now make it
possible to generate enamel fractures when debonding metal brackets; this has, of course, always been
possible in teeth with severely compromised crowns as a result of extensive restoration. Manufacturers
can now make adhesion enhancers and adhesives that are far stronger than is necessary for orthodontic
use. And so the quest is to maximise bond strengths without endangering the integrity of the enamel
surface.
In addition, self-ligating brackets have much more rigid bracket bodies which are harder to deform on
debonding. The conventional method of 'snapping off' directly bonded brackets with a small, sharp rotation
of the wrist works well on siamese brackets but less well on more rigid brackets. We have tried lift off
debonding instruments (LODI) for self-ligating brackets in the belief that the pads of the instrument would
support the enamel surface and eliminate the possibility of enamel fractures; while this instruments worked
well, enamel fractures were not eliminated.
1
The best way to removed self-ligating brackets is to use AEZ 90° debonding pliers and squeeze firmly but
gently on one pair of tiewings only as shown in
Figure 6.4; the bracket will (noiselessly!) separate
from the enamel surface. It is not necessary to twist
or rotate the bracket – it just floats off the tooth!
Situations where particular care needs to be taken
include teeth with large restorations including
molars with moderate sized buccal amalgam
restorations.
A comprehensive paper on enamel surfaces after

orthodontic bracket debonding and Campbell (1995)
has published the optimum method of debonding.
As a result of the findings of this paper the following
technique is recommended:
• use of fluted tungsten carbide bur to

remove gross adhesive. Can use
disclosing solution to improve
visibility of adhesive. Do not touch
the enamel surface with bur.
Figure 6.4: Debonding technique for self-ligating brackets
• use abrasive points or cups to
1
Ormco AEZ 803-0104
1 0 0 B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S
remove residual adhesive

• final polish with prophylaxis paste or pumice slurry
Another paper by Hong and Lew (1995) compared:
• band removing pliers

• slow speed tungsten carbide bur
• high speed ultrafine diamond bur
• high speed tungsten carbide bur
• high speed white stone finishing bur
High speed ultrafine diamond burs and white stone finishing burs were found to be unsuitable for removing
composite adhesive. The high-speed burs were used with a water spray, which made it more difficult for
the operator to distinguish between composite and enamel surface. The high-speed tungsten carbide bur
produced the smoothest surface (Surface Roughness Index) but was fourth in the Composite Remnant
Index (CRI).
A good review of debonding is given by Banks (2004).
Ireland et al (2005) carried out an interesting study which compared enamel loss at bonding, debonding
and enamel clean-up using 37% ortho-phosphoric acid and Transbond and 10% polyacrylic acid and Fuji
Ortho LC using four different debonding methods:
• debonding pliers
• ultrasonic scaler
• slow speed tungsten carbide bur
• high speed tungsten carbide bur
The authors found that using 37% ortho-phosphoric acid removed more enamel than 10% polyacrylic acid
and that post debond, more Transbond than Fuji Ortho LC remained on the enamel surface. The least
enamel was removed using a slow speed tungsten carbide bur (up to approximately 5 µm) with both
materials and the most with an ultrasonic scaler or high speed tungsten carbide bur (up to approximately
30 µm). More enamel was lost using Transbond that Fuji Ortho LC for all debonding methods.
References
Aguirre MJ, King GJ, and Waldron, JM (1982)
Assessment of bracket placement and bond strength when comparing direct bonding and indirect bonding
techniques
American Journal of Orthodontics and Dentofacial Orthopaedics 82: 269-276
Alexander RG (1986)
The Alexander Discipline: Contemporary concepts and philosophies
Glendora, Ormco Corporation
Balut N, Klapper L, Sandrik J and Bowman D (1992)
Variations in bracket placement in the preadjusted appliance
Banks PA (2004)
Efficient debonding
Orthodontics 1: 251-253
Bouschlicher MR, Whalen SR and Dawson DV (2002)
Intrapulpal temperature increases with LED, QTH and Plasma arc photoinitiation
The IADR/AADR/CADR 80th General Session (March 6-9, 2002) San Diego, California, Dental Materials VIII:
Others – Non-metallic
http://iadr.confex.com/iadr/2002SanDiego/techprogram/abstract_13520.htm
Accessed: 5 January 2006
B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S 1 0 1
Cacciafesta V, Süßenberger U, Jost-Brinkman P-G and Miethke R-R (1998)

Shear bond strengths of ceramic brackets bonded with different light-cured glass-ionomer cements: an in vitro
study
European Journal of Orthodontics 20: 177-187
Cacciafesta V, Jost-Brinkman P-G, Süßenberger U and Miethke R-R (1998)
Effects of saliva and water contamination on the enamel shear bond strength of a light-cured glass ionomer
cement
Cacciafesta V, Sfondrini MF, Jost-Brinkmann PG and Boehme A (2002)
LED Curing lights prove effective for orthodontic bonding
Journal of Clinical Orthodontics 36: 461-465
Campbell PM (1995)
Enamel surfaces after orthodontic bracket debonding
Angle Orthodontist 65: 103-110
Catania JA, Cohen BD and Deeney MR (1990)
The use of labial root torque and the tie-forward technique in the treatment of maxillary skeletal retrusion and
severe arch length discrepancy
Dunn WJ and Taloumis LJ (2002)
Polymerization of orthodontic resin cement with light-emitting diode curing units
Evans LJ, Peters C, Flickinger C, Taloumis L and Dunn W (2002)
A comparison of shear bond strengths of orthodontic brackets using various light sources, light guides and cure
times
American Journal of Orthodontics and Dentofacial Orthopaedics 121; 510-515
Fay R-M, Lu H and Powers JM (2002)
Mechanical properties of composite cured with LED and QTH curing lights
The IADR/AADR/CADR 80th General Session (March 6-9, 2002) San Diego, California, Dental Materials VI:
Polymer Materials – Mechanical Properties and Degradation Program
Fowler PV (1990)
Variation in the perception of ideal bracket location and its implication for the preadjusted appliance
British Journal of Orthodontics 17: 306-310
Hickham JH (1993)
Predictable indirect bonding
Hocevar RA and Vincent HF (1988)
Indirect versus direct bonding: bond strength and failure location
Hong YH and Lew KKK (1995)
Quantitative and qualitative assessment of enamel surface following five composite removal methods after
bracket debonding
Ireland AJ, Hosein I and Sherrif M (2005)
Enamel loss at bond-up, debond and clean-up following the use of a conventional light-cured composite and a
resin-modified glass polyalkenoate cement
European Journal of Orthodontics 27: 413–419
Kalange JT (1999)
Ideal placement with APC brackets and indirect bonding
Journal of Clinical Orthodontics 33; 516-526
Koo BC, Chung C-H and Vanarsdall R (1999)
Comparison of the accuracy of bracket placement between direct and indirect bonding techniques
Mavropoulos A, Staudt CB, Kiliaridis S and Krejci I (2005)
Light curing time reduction: in vitro evaluation of new intensive light-emitting diode curing units
European Journal of Orthodontics 27: 408–412
Mayes JH (2000)
Curing lights: an overview
Clinical Impressions 9: 15-28
1 0 2 B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S
McLaughlin RP and Bennett JC (1995)

Bracket placement with the preadjusted appliance
Millett DT, Letters S, Roger E, Cummings A and Love J (2001)
Bonded molar tubes – an in vitro evaluation
Mills RW, Jandt KD and Ashworth SH (1999)
Dental composite depth of cure with halogen and blue light emitting diode technology
British Dental Journal 186: 388-391
Moskowitz EM, Knight LD, Sheridan JJ, Esmay T and Tovilo K (1996)
A new look at indirect bonding
Nakaji NK and Sheffield (1981)
Table Clinic, AAO Annual Session
Parr GA and Rueggeberg FA (2002)
Spectral analysis of commercial LED dental curing lights
The IADR/AADR/CADR 80th General Session (March 6-9, 2002) San Diego, California, Dental Materials VIII:
Others – Non-metallic
Redmond WJ, Redmond J and Redmond WR (2004)
The OrthoCAD bracket placement solution
Shiau J-Y, Rasmussen ST, Phelps AE, Enlow DH and Wolf GR (1993)
Bond strength of aged composites found in brackets placed by an indirect technique
Silverman E, Cohen M, Gianelly AA and Dietz VS (1972)
A universal direct bonding system for both metal and plastic brackets
American Journal of Orthodontics 62: 236-244
Sinha PK, Nanda RS, and Ghosh J, (1995)
A thermal-cured, fluoride releasing indirect bonding system
Sondhi A (1999)
Efficient and effective indirect bonding
Swain BF (1986)
Straight wire design strategies: five year evaluation of the Roth modification of the Andrews Straight-Wire
Appliance
In: Graber LW ed. Orthodontics State of the Art Essence of the Science: St Louis, The CV Mosby Company
Taylor NG and Cook PA (1992)
The reliability of positioning preadjusted brackets: an in vitro study
British Journal of Orthodontics 19: 25-34
Thomas RG (1979)
Indirect bonding: simplicity in action
Wendl B and Droschl H (2004)
A comparative in vitro study of the strength of directly bonded brackets using different curing techniques
Zachrisson BU and Brobakken BO (1978)
Clinical comparison of direct versus indirect bonding with different bracket types and adhesives

Bracket Placement

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B R A C K E T P L A C E M E N T , B O N D I N G A N D D E B O N D I N G T E C H N I Q U E S 8 5

Bracket placement, bonding and

Characteristics of an ideal bracket site

SLOT SITING FE ATURES

• parallel vertical bracket components

SLOT SITING FE ATURES FOR TRANSL ATION BRACKETS

The FACC and the FA point

The FA (facial axis) point is the midpoint of the FACC.

Bracket placement studies

Theoretical bracket placement charts

• anatomical crown heights

Recommended method of bracket placement

4 • check that clinical crown heights

3 approximate to anatomical crown

Then for all teeth:

OrthoCAD bracket placement solution

• a pen sized wand with

• bracket positioning can be fine tuned

The technique is fully described by Redmond et al (2004).

Variations in use of brackets

Over angulating brackets

The reasons against bonding molars are as follows:

• the inferior quality of etch pattern obtained on molars

• conventional curing lights

Conventional curing lights

High performance halogen curing lights

Plasma arc lights

• halogen bulbs have a life of about 50 hours

• the bulb, reflector and filter degrade

Light emitting diodes (LEDs) have lifetimes of

Cacciafesta et al (2002) compared

halogen light groups using a 10 second curing time.

Why indirect bonding?

• more accurate bracket and tube placement

The disadvantages of indirect bonding are:

The development of indirect bonding

Indirect bonding versus direct bonding

1. Pour up the model in pure stone (not plaster or a plaster/stone mix)

A comprehensive paper on enamel surfaces after

• use of fluted tungsten carbide bur to

remove residual adhesive

Another paper by Hong and Lew (1995) compared:

• band removing pliers

A good review of debonding is given by Banks (2004).

Cacciafesta V, Süßenberger U, Jost-Brinkman P-G and Miethke R-R (1998)

McLaughlin RP and Bennett JC (1995)

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