Frequent handling mistakes

during bonding 10
Z. Cai, M. Iijima, T. Eliades, W. Brantley

10.1 Introduction
Bonding of brackets to tooth enamel or the surface of a dental restoration is a critical
procedure in clinical orthodontics. It is directly related to the effectiveness of the ortho-
dontic treatment. The bonding process involves multiple steps, and mistakes in each
step could lead to bonding failure. This chapter presents the sequential steps, along
with important related factors, for the direct bonding of orthodontic brackets using
light-cured composite resin adhesives, with a focus on common handling mistakes.

10.2 Pumicing of tooth surface

Cleaning of the enamel before bonding in general is not necessary, with the excep-
tion of when visible layers of integuments are present on the enamel surface.
Research has suggested that the bonding to clean enamel surfaces, whether these
surfaces had been pumiced or not, was not affected, i.e., no change in resin tag
length and retention capacity of the adhesive. However, circumstances change
when the clinician deals with compromised hygiene, and it is suggested that no gen-
eral rule of pumicing should be implemented in routine orthodontic practice. The
clinician must also decide about adopting a self-etching primer to facilitate more
efcient (time reduction of about 1 min) bonding or instead relying on a traditional
bonding technique that is more time consuming but does not have the potential side
effects of the new primer.

10.3 Effect of uoridation on enamel bonding

Fluoridation of the enamel has long been considered a parameter with an unfavorable
effect on longevity of the bond. However, there is some dispute on this topic, and
in vitro research as well as clinical failure rate studies have suggested that there
may be a threshold effect for uoride content of the enamel, implying that low uoride
levels could be tolerated without adverse effects on bonding. For example, pumicing
with uoride-containing paste has not been shown to affect bond strength, whereas
increased uoride levels along with the use of a self-etching primer might decrease
the bond strength or failure rate. A possible source of the apparent dispute in the

Orthodontic Applications of Biomaterials. http://dx.doi.org/10.1016/B978-0-08-100383-1.00010-2

Copyright 2017 Elsevier Ltd. All rights reserved.
172 Orthodontic Applications of Biomaterials

literature may be that self-etching primers, which yield considerably decreased pene-
tration depth and much shorter resin tags, might be more technique sensitive. Accord-
ingly, variation in the enamel structure might prove deleterious for bond strength with
the use of a self-etching primer. Contrary to the traditional belief, however, uorida-
tion does not seem to alter the bond strength when it is used with conventional etching.
Support for this hypothesis is provided by bonding studies where acidulated phosphate
uoride etching solutions were used.

10.4 Enamel contamination, tooth whitening, and

alternative bonding surfaces
Enamel surface contamination is a common mistake during bonding of appliances. After
applying the 37% phosphoric acid gel on enamel surfaces, the gel has to be completely
removed by thorough rinsing with water. The etched enamel surface has to be dried with
moisture- and oil-free compressed air, which results in a frosted appearance, before the
thin coat of primer can be applied. Incomplete removal of the etching gel or failure to dry
the etched enamel is a critical mistake that must be avoided.
Saliva contamination on the etched and dried enamel surface is another common
mistake. The remedy is to reetch the surface, even though the contaminated enamel
after drying has the desired frosted appearance. Barely drying the etched enamel
that was contaminated by saliva and proceeding to the next step will result in poor
bonding. Because the bonding of a bracket with a hydrophilic self-etching primer sim-
plies the process, combining etching and priming into a single step, it is now widely
used in clinical orthodontics. Studies have shown that contamination of the enamel by
water, saliva, and blood, before and after priming with a hydrophilic self-etching
primer, has little adverse effect on bond strength.
If a new patient has his/her tooth whitening (either an in-ofce or at-home method)
performed very recently, increased bonding failure can be expected if the bonding is
conducted immediately after the whitening. The origin of this problem is the high con-
centration of oxygen that is present on the enamel surface after tooth whitening. This
excessive oxygen will inhibit the free radical polymerization of the composite resin.
There are conicting results from in vitro studies of the effects of tooth whitening
on bracket bond strength to enamel. When hydrogen peroxide or carbamide peroxide
was used for tooth whitening, reduced or unchanged shear bond strength of brackets to
the enamel was reported when bonding was performed immediately following the
whitening. Treating whitened enamel with an antioxidizing agent can eliminate the
potentially negative effect on bond strength. When bonding was performed 1 week
after the tooth whitening, no negative effect of tooth whitening on the bracket bonding
was observed.
Clinically, if the patient has tooth whitening performed recently or is still undergo-
ing at-home whitening, it is necessary for the patient to stop the tooth whitening before
the bonding procedure. The bonding visit should be scheduled for at least 1 week after
the end of the whitening. If the bonding has to be conducted immediately, use of an
Frequent handling mistakes during bonding 173

antioxidating agent such as 10% sodium ascorbate to pretreat the enamel can effec-
tively eliminate the negative effect of the whitening on bonding.
When bonding to porcelain crowns or porcelain-fused-to-metal crowns, a special
hydrouoric acid etching gel for porcelain should be used. Effective etching can
only be achieved when sufcient etching time is used. A special primer must also
be used after the etching. Detailed procedures have to be followed as recommended
by the manufacturer to ensure reliable bonding.

10.5 Priming of enamel surface

The use of a bonding agent, or a liquid resin or primer in orthodontics terminology, is
accompanied by a number of risks for the longevity of the bond to enamel. As this
polymer does not contain llers, the polymerization-induced shrinkage is expected
to be higher than that of its composite resin counterpart, with unpredictable conse-
quences for the integrity of the enameleadhesive interface. Moreover, a relatively
thick layer of primer may release more compounds, such as monomers, additives,
and potentially Bisphenol A (BPA). To avoid this biocompatibility concern, residents
are generally instructed to reduce the thickness of the primer layer by applying an air
stream with the use of a syringe. This procedure, however, can introduce other prob-
lems. Incorporation of air bubbles increases the porosity of the primer layer, predispos-
ing it to failure or water absorption. Oxygen inhibition of the polymerization may
further degrade the properties of this layer, with an adverse outcome on the interface
with enamel. It is recommended that the clinician use a brush with thick and short bris-
tles, rather than thin and long bristles that could carry more resin when dipped into the
well containing the primer. A sponge should not be used, as this could disturb the
development of the desired honeycomb type of resulting surface pattern.

10.6 Application of adhesive paste

Removal of the excess adhesive around brackets should be complete prior to photocur-
ing. The use of rotary instruments on the enamel after polymerization can lead to two
undesirable effects: (1) the development of scratches on the enamel and (2) in the case
of a ceramic bracket, the generation of pits or cracks that may have catastrophic con-
sequences. Because ceramic brackets are brittle, stress concentrations from inadvertent
excessive loading at surface defects lead to crack propagation and catastrophic frac-
ture. The underlying principles have previously been discussed in Chapter 3, where
it was noted that fracture is of greater clinical concern for single-crystal, rather than
polycrystalline, alumina brackets.
Care should be taken in handling the brackets. Avoid contacting the brackets with
bare hands, since the grease found on hands can contaminate the bracket bases. When
applying the composite resin adhesive to the bracket base, the bracket base should be
free from moisture, oil, or powder from the latex gloves worn by the operator. If there
174 Orthodontic Applications of Biomaterials

is any doubt about possible contamination of the bracket base, dipping the bracket base
briey in acetone is effective in eliminating the contamination.
When applying the composite resin adhesive to the bracket base, it is particularly
important to be attentive to the viscosity and consistency of the initial segment of
the adhesive squeezed from the syringe. If the adhesive shows reduced viscosity
from partial polymerization, discard the initial segment. Always use fresh composite
from the syringe for bonding. The adhesive should be carefully placed on the bracket
base to ll voids in the mesh or undercuts on the base.
At present, using brackets with precoated composite resin on the base (APC
Adhesive Coated Appliance System, 3M Unitek) can avoid mistakes associated
with applying composite resins on bracket bases.

10.7 Placement of brackets on teeth

Placing brackets while the dental operatory light is illuminating the teeth is a mistake to
be avoided. When the operatory light is incident on the teeth where brackets are being
placed, the composite resin adhesive on the bracket base will be partially polymerized
before the clinician starts to nalize the bracket positions. In vitro studies have shown
that changing the bracket position when the adhesive has partially polymerized will
signicantly reduce the bond strength of the bracket to enamel. Even with the opera-
tory light turned off, the ambient light can lead to partial polymerization of the com-
posite adhesive if there is a prolonged time period between bracket placement and
nalizing the bracket position. An amber-colored plastic light shield can be used to
cover the mouth of the patient and protect the placed brackets from the operatory light.

10.8 Light-curing of adhesive

The output from any light-curing unit used for bracket bonding should be regularly
checked to ensure that the radiation meets the manufacturer specication. Use of a
halogen lightecuring unit with an aged halogen bulb often results in an insufcient
light output and reduced curing ability. While the output from contemporary light-
curing units that have light-emitting diodes (LEDs) appears to be stable over time, their
light output should also be inspected periodically.

10.9 Need for patient rinsing after bonding

Recent evidence suggests that the use of BisGMAeTEGDMA adhesive pastes during
bonding can result in BPA leaching in vivo, but this concern can be alleviated by
rinsing after bonding. Analysis of the expectorated oral rinse solutions revealed that
when patients rinsed two times, the second rinsing solution contained BPA levels at
the order of baseline values (perhaps from water contamination by the lining of pipes).
Frequent handling mistakes during bonding 175

Thus, any potential concern from BPA leaching should be mitigated by adding this
rinsing step by the patient to the bonding procedure.

10.10 Debonding
The excessive use of rotary instruments to remove the adhesive after debonding is a
concern from many perspectives which relate to: (1) pulp protection from excessive
heat; (2) the generation of aerosols with microbial content that could contaminate
the operatory and also contain ller particles or bur components that could be inhaled
by the patient and dental personnel; and (3) heat shock of the composite resin with po-
tential release of BPA. It is suggested that treatment remove as much composite resin
as possible without the use of rotary instruments. A way to achieve this result is by
adjusting the bracketeadhesiveeenamel interfacial characteristics. Use of brackets
with a mesh base or etched base to provide micromechanical retention with the

Table 10.1 Bonding failures between bracket base and composite resin
adhesive
Cause of bonding failure Preventive measures

Excessive force from tight occlusal Place bite blocks to avoid the tight occlusal
contact or from appliances contact
Change to an archwire with less stiffness
Use elastomeric O ring to partially engage the
newly bonded bracket instead of using the
ligature tie
Contaminated bracket base Avoid contacting bracket with hand
Clean bracket base with acetone
Use powder-free gloves
Be certain that the compressed air is dry and oil
free
Moving bracket after initial setting Turn operatory light away before placing brackets
of the adhesive on teeth
Use light shield to cover patient mouth while
waiting for clinician to nalize bracket position
Adhesive partially polymerized Discard initial portion of adhesive dispensed from
when dispensed on bracket base syringe
Check expiration date of adhesive
Adhesive not properly placed on Carefully dispense adhesive on bracket base to ll
bracket base mesh and undercuts on base
Inadequate light-curing Check light output of light-curing unit
Replace aged light bulb in halogen lightecuring
unit
176 Orthodontic Applications of Biomaterials

Table 10.2 Bonding failures between adhesive and tooth

Cause of bonding failure Preventive measures

Etching gel left on enamel before placing Thoroughly rinse enamel surface with water
brackets after etching
Contaminated enamel surface after Be certain that enamel surfaces are
etching completely dry and have frosted appearance
Compressed air used should be dry and oil
free
Reetch enamel if etched enamel was
contaminated by saliva
Porcelain crown not etched properly Use special hydrouoric acid (HF) gel to
etch porcelain for adequate time
Use special primer after HF gel etching
Inadequate light-curing See Table 10.1
Composites partially polymerized before See Table 10.1
bracket position was nalized

adhesive can enhance the interfacial properties, thereby shifting the desired cohesive
fracture (through the adhesive) closer to the enameleadhesive interface. The rule of
less adhesive on the bracket for debonding means faster cleanup is served by this
practice better, rather than by having a thick layer of adhesive with the characteristic
mesh imprint left on the surface after debonding.

10.11 Troubleshooting bonding failures

Bonding failure is a serious issue clinically. The clinician should carefully examine the
failure location and attempt to elucidate the possible cause of the failure, so that effec-
tive measures can be implemented to prevent a similar future bonding failure. In gen-
eral, since the adhesive layer is very thin, bonding failures largely occur at one of the
two bonding interfaces: between the adhesive and the enamel or between the adhesive
and the bracket base. The two tables list the possible causes of bonding failures and the
procedures to prevent them (Tables 10.1 and 10.2).

Further reading
1. Bishara SE, Sulieman AH, Olson M. Effect of enamel bleaching on the bonding strength of
orthodontic brackets. Am J Orthod Dentofac Orthop 1993;104:444e7.
2. Miles PG, Pontier JP, Bahiraei D, Close J. The effect of carbamide peroxide bleach on the
tensile bond strength of ceramic brackets: an in vitro study. Am J Orthod Dentofac Orthop
1994;106:371e5.
Frequent handling mistakes during bonding 177

3. Watts DC. Orthodontic adhesive resins and composites; principles of adhesion. In:
Brantley WA, Eliades T, editors. Orthodontic materials: scientic and clinical aspects.
Stuttgart: Thieme; 2001. p. 189e200.
4. Eliades T, Eliades G. Orthodontic adhesive resins. In: Brantley WA, Eliades T, editors.
Orthodontic materials: scientic and clinical aspects. Stuttgart: Thieme; 2001. p. 201e19.
5. Papazoglou E. Bonding to non-conventional surfaces. In: Brantley WA, Eliades T, editors.
Orthodontic materials: scientic and clinical aspects. Stuttgart: Thieme; 2001. p. 253e69.
6. Uysal T, Basciftci FA, Usumez S, Sari Z, Buyukerkmen A. Can previously bleached teeth
be bonded safely? Am J Orthod Dentofac Orthop 2003;123:628e32.
7. Bulut H, Turkun M, Kaya AD. Effect of an antioxidizing agent on the shear bond strength of
brackets bonded to bleached human enamel. Am J Orthod Dentofac Orthop 2006;129:
266e72.
8. Gioka C, Eliades T, Zinelis S, Pratsinis H, Athanasiou AE, Eliades G, et al. Characterization
and in vitro estrogenicity of orthodontic adhesive particulates produced by simulated
debonding. Dent Mater 2009;25:376e82.
9. Oliveira AS, Barwaldt CK, Bublitz LS, Moraes RR. Impact of bracket displacement or
rotation during bonding and time of removal of excess adhesive on the bracket-enamel bond
strength. J Orthod 2014;41:124e7.
10. Kloukos D, Sifakakis I, Voutsa D, Doulis I, Eliades G, Katsaros C, et al. BPA qualitative
and quantitative assessment associated with orthodontic bonding in vivo. Dent Mater 2015;
31:887e94.