Orthodontic adhesives/certified fixed orthodontic courses by Indian dental academy

UPDATE
ORTHODONTIC ADHESIVES
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
 Introduction
 Common points about adhesives
 Materials used as adhesives
 Composites
 Generations of adhesive
 Other adhesive materials
 Clinical application of adhesives–
Bonding in Orthodontics
 Updates
 Conclusion www.indiandentalacademy.com

INTRODUCTION
 Tooth movement
 Attachment of brackets on tooth
 Banding
 Bonding
 Acid Etch technique – Buonocore – 1955
 Newman – Epoxy resin 1965

Benefits of bonding
 Aesthetics
 Easier plaque control
 Decreased irritation of gingival
tissues
 Absence of interproximal space after
the completion of treatment.
PATIENT:

Benefits of Bonding
PRACTITIONER:
 eliminates pre-treatment separation
of teeth & needless to mention it also
greatly decreases chair side time.
 direct bonding makes it easier to
detect & treat dental caries

ADHESION
“The state in which two surfaces are
held together by interfacial forces
which may consist of valence forces
or interlocking forces or both”

ADHESIVE
“ is a material frequently a viscous fluid that
joins two surfaces together and solidifies
and therefore is able to transfer a load from
one surface to the other.
ADHEREND
Material to which an adhesive is
applied is called Adherend

SURFACE WETTING & CONTACT ANGLE
“WETTING” use a fluid that will flow and “wet” an
adherend
“CONTACT ANGLE” which is nothing but an angle
formed by the adhesive with the adherend at
their interface.
IMPORTANCE
The smaller the contact angle, the better able,
is the adhesive to fill in irregularities in the
surface of the adherend.

MECHANISMS OF ADHESION
 MECHANICAL ADHESION
 ADSORPTION ADHESION
 DIFFUSION ADHESION
 ELECTROSTATIC ADHESION

 MECHANICAL :
INTERLOCKING OF ADHESIVE WITH
IRREGULARITIES IN THE SURFACE OF
THE ADHEREND.
 ADSORPTION :
CHEMICAL BONDING BETWEEN THE
ADHESIVE AND ADHEREND

 ELECTROSTATIC:
THERE IS AN ELECTRICAL DOUBLE
LAYER AT THE INTERFACE OF A
METAL AND POLYMER THAT IS PART
OF THE TOTAL ADHESIVE SYSTEM
 DIFFUSION :
INTERLOCKING BETWEEN MOBILE
MOLECULES, SUCH AS THE ADHESION
OF TWO POLYMERS THROUGH
DIFFUSION OF POLYMER CHAIN ENDS
ACROSS AN INTERFACE.

Requirements for adhesive
systems
 Wetting: An adhesive must give
good wetting of the adherend.
 Thickness: Too great thickness
can lead to poor bond strength.
 Strength: of the set adhesive
must be taken into consideration.www.indiandentalacademy.com

 Viscosity: The adhesive should
have a suitable viscosity to enable
it to flow readily over the surface of
adherend
 Dimensional Stability: The setting
time of the adhesive should occur
without excessive dimensional
changes i.e.., little expansion or
contraction.

GIC COMPOSITE
RESIN
MODIDIFIED
GIC
COMPOMER
PMCR’s (Poly-acid
modified resin)
MATERIALS

COMPOSITE RESINS
Types
Components
Method of activation
 Chemical
 Light cure
Curing lights
Clinical application
 Etching
 Enamel Bonding
 Dentine Bondingwww.indiandentalacademy.com

2 basic types resins for orthodontic bonding
Acrylic
Diacrylate resins
/ Based on Self-curing acrylics
/ Methylmethacrylate monomer &
ultra fine powder
/ form linear polymers only
/ filled or unfilled forms
/ e.g Orthomite, Genie
/ Plastic brackets
/ Based on acrylic modified Epoxy
resin
/ Bis GMA or Bowen’s resin
/ Polymerised also by cross linking
into 3 dimensional network
/ Cross linking – greater strength
/ filled or unfilled forms
/ e. g Concise, Phase II

COMPONENTS
•PRINCIPLE
•DILUENT
•FILLERS
•COUPLING AGENTS
•INITIATOR /ACTIVATOR COMPONENTS

COMPOSITES
RESINS FILLERS
Bis-GMA /
URETHANE-
DIMETHACRYLATE
TEGMA-REDUCES
VISCOSITY
QUARTZ
FUSED SILICA
ALUMINO- SILICATES
BARIUM OXIDES
Coupling agent:
vinylsilane –helps the filler and polymer for
reinforcement to occur .

TYPES-ACCORDING TO SIZE OF
FILLER PARTICLES
CONVENTIONAL 1-50 µm
MICROFILLED 0.04 µm
HYBRID
CLINCAL APPLICATION:
•LARGER FILLER PARTICLES-EXTRA BOND STRENGTH.
•CAREFUL REMOVAL IS NECESSARY DUE TO
ACCUMULATION OF PLAQUE.

ACTIVATION
CHEMICAL LIGHT CURED
Initiator Activator Uv-light Visible light
Benzoyl
peroxide
N,N’
DIMETHYL
P-TOLUIDENE
Benzoynmethyl
ether
CAMPHORO
QUINONE

CURING LIGHTS
Conventional curing lights
High performance halogen
lights (optilux 501)
Plasma Arc Lights (PAC)
Lasers
LED’s (Light emitting diode)

Conventional Curing lights: Use halogen
bulbs filtered to produce blue light.
Cure adhesives under bracket in 20-30 sec.
High performance halogen curing
lights:
80 watts tungsten/quartz/halogen bulb
Cures under metal brackets in 8 seconds and
under ceramic brackets in 5 seconds .
Has boost mode to increase the output up to
1000 watts. hence allows metal brackets to be
cured in 5 seconds

Plasma arc lights:
generates a lot of heat and large fan is
required.
Adhesive is cured in 5 seconds under metal
brackets and 3 seconds under ceramic brackets
Laser lights:
emits monochromatic coherent light
source
Generate lot of heat
cumbersome

Led’s(LIGHT EMITTING DIODES)
1995 mills et al
Solid state light emitting diode technology
10 sec cure
Cool, safe light, no damage to the tooth pulp
e.g.Ledmax-4

Clinical application of composite

Composition:
ENAMEL STUCTURE
Hardest mineralized tissue in body.
96% INORGANIC PORTION
Crystalline calcium hydroxy-apatite crystals
4% ORGANIC MATERIAL & WATER

Structural unit of the enamel.
RODS &PRISMS.
KEY HOLE SHAPED.
CENTRAL BODY & EXTENSION TAIL.
INTERPRISMATIC MATERIAL.

MICROSCOPIC STRUCTURE
SCHEMATIC DIAGRAM

ACID ETCHING:
REMOVAL OF SURFACE DEBRIS AIDS BONDING
PORES CREATED RESIN PENETRATES
CREATES TAG LIKE EXTENSIONS
MECHANICAL INTERLOCKING
INCREASES SURFACE ENERGY OF ENAMEL
IMPROVES WETTING.
Acid Etching

Types of etchants
 Strong acids 37% phosphoric acid for 15
seconds
provides a strong bond
.
 Weak acids 2.5% nitric acid (or)
17% maleic acid for 30-60
seconds

PATTERNS OF ACID ETCHING

Type 1- Intraprismatic –
removal of prism cores

Type 2 – Interprismatic –
removal of prism peripheries

Type 3 – both type 1 & 2

ETCHING IN FLUORIDATED TEETH
.
Fluoride ion Hydroxy–apatite crystal
Resistant to acid-dissolution
Caries
prevention
Hence fluoridated teeth requires longer
etching time.

Dentine Bonding
 Disadvantages of Dentine Bonding
 Smear Layer
 Moist dentine

SMEAR LAYER
WHEN WE PREPARE THE TOOTH , THE DENTINAL
SURFACE WITH OTHER PARTICLES FORM A SMEAR
LAYER WHICH WILL PREVENT THE COMPOSITE
BONDING

CONDITIONERS
ACID SOLUTIONS
CAPABLE OF DISSOLVING (OR) AT LEAST
SOLUBILIZING THE SMEAR LAYER.
HENCE MORE EXPOSURE OF DENTINE TO
BONDING SYSTEMS.
REMOVAL OF SMEAR LAYER

Examples of Conditioners
/35%-37% Phosphoric acid
/10% Phosphoric acid
/maleic acid
/EDTA
/Citric acid + 3% ferric chloride
37% phosphoric acid is a good
etchant and conditioner.

PRIMERS
Difunctional
Hydrophilic Hydrophobic
Unfilled methacrylate groups
Dentine RESIN
HEMA
Hydroxy ethyl methacrylate

GENERATIONS
OF
BONDING AGENTS

RESIN CONTAINING
GLYCEROPHOSPHORIC ACID
DIMETHACRYLATE
BOWEN
N- PHENYL GLYCINE
&GLYCIDYL METHACRYLATE
(NPG-GMA)
BUONOCORE
(1956)
DRAWBACK •POOR DENTINE BONDING
•ENAMEL BONDING IS GOOD.
I - GENERATION
Bonding- Chelation of bonding agent to calcium of dentine

II - GENERATION
(1978)
IONIC BONDING
DRAW BACK : BONDING TO SMEAR LAYER
REQUIRE MECHANICAL PREPARATION
Bis-GMA (or) HEMA
Unfilled resins
Calcium in dentine

PRINCIPLE: PARTIALLY REMOVED (OR)
MODIFIED THE SMEAR LAYER
ETCHING OPENS DENTINAL TUBULES
PRIMER
META (or) BPDM
MODIFIES SMEAR
LAYER
ATTACHES TO
COMPOSITES
DRAWBACK: •PRIMER , DOES NOT PENETRATE THE SMEAR
LAYER
•ADHESIVE RETENTION DECREASES AFTER
SOME TIME
III - GENERATION

IV - GENERATION
COMPLETE REMOVAL OF SMEAR LAYER
HYBRIDIZATION:REPLACEMENT OF HYDROXY-
APATITE AND WATER IN THE SURFACE DENTIN WITH
RESIN
HYBRID :RESIN IN COMBINATION WITH REMAINING
COLLAGEN FIBRE.
•TOTAL - ETCH TECHNIQUE.
•MOIST – DENTINE CONCEPT.

V - GENERATION
SELF ETCHING PRIMERS
ONE –BOTTLE SYSTEM
•PRIMER AND ADHESIVES ARE COMBINED INTO ONE
SOLUTION
SHOW HIGH BOND STRENGTH VALUES BOTH TO THE
ETCHED ENAMEL AND DENTIN DUE TO ADHESIVE
LATERAL BRANCHES AND HYBRID LAYER FORMATION.

VI - GENERATION
ETCHNG WAS NOT REQUIRED AT LEAST AT THE
DENTINAL INTERFACE
They contained dentin conditioning agent as
one of their components
Drawbacks: Multiple components
Multiple steps

VII - GENERATION
i-bondETCHING PRIMING
BONDING
Shear bond strength not affected –any type of curing
light
Similar adhesion to prepared and unprepared
enamel
Desensitizers were added.

Setting Reaction: The hydrogen ions of the acid attack
the glass particles in the presence of water releasing
calcium, strontium, and aluminium ions. The metal ions
combine with the carboxylic group of the polyacid to
form the polyacid salts matrix and the glass surface is
changed to a silica hydrogel.
GLASS IONOMER CEMENTS
Invented -1969 reported 1971 by WILSON AND KENT
POWDER LIQUID
poly alkenoic acid
(carboxyl containing acid)
Flouroalumino
silicate glass

GIC ‘S
ADVANTAGES DISADVANTAGES
FLUORIDE RELEASE
HYDROGEL PHASES
MOISTURE
TOLERANCE
BOND STRENGTH
LESS THAN THAT
OF COMPOSITE.
HYDROGEL PHASE:
Responsible for the uptake and release
of added environmental fluoride from
topical gels, rinses & dentifrices.

GIC’s used for BONDING TO
CERAMIC BRACKETS
CACCIAFESTA et al (1998) (european journal of
orthodontics)
The lower bond strength of glass ionomer
cements might be advantageous with ceramic
brackets where high bond strengths have
been associated with enamel damage.

Polyacid +fluroalumino
silicate Glass particles
Monomer+photoinitiator
+light
Monomer+initiator+
catalyst
RMGIC’S
acid –base
polymerization (light –
initiated)
polymerization (chemical
initiator)
COMPONENTS REACTION TYPE

ADVANTAGES:
 polymerization proceeds faster than acid-base
reaction resulting in improvement of physical
properties, especially resistance.
 RMGIC-tolerates moisture similar to GIC’s.
Improved physical properties & more stable
hydrogel phases compared with GIC’s

polymerization of resin monomers hastens initial
hardening of RMGIC,s without interfering with
acid-base setting reactions (or) any other properties.
Micromechanical interlock
after polymerization

Silver et al :AJO (1995)
Found excellent long term adhesion
with such materials in the absence of
enamel etching
BISHARA et al : AJO (1999)
Advised etching of enamel for
sufficient bond strength
STUDIES :

BONDING

Bonding
Direct Indirect

DIRECT BONDING
 Easier, Faster
 Less expensive
 Drawbacks
 proper positioning is crucial.
 Has to be done rapidly and accurately.

INDIRECT BONDING
 Placing brackets in a model
 Use template or tray to transfer
 Common agent – “No-mix” chemically
activated materials
 More useful in Lingual attachments

Current categories of Adhesive bonding
According to Howard E. Srassler
(Compendium - June 2003 )
1.Total etch adhesive bonding
2. Self – etch adhesive bonding

Total Etch Adhesive bonding

1)Cleansing
2)Enamel conditioning or acid etching
3)Priming
4)Bonding
Bonding or adhesion to the
enamel is done in the
following procedure .

Pre-treatment
 Cleansing Improves wetting
 Acid etching Improves adhesion
micromechanical retention.
Pre-treatment is necessary as mouth is
complicated by saliva ,acquired pellicle ,
different organic and inorganic
components of enamel and dentin.

Salivary pellicle
When a tooth is cleaned in situ,
salivary proteins and glycoproteins with
a strong affinity for enamel very quickly
adsorb to the tooth surface and form a
very thin layer called salivary pellicle.

CLEANSING
Removal of salivary pellicle &
contaminants
Material used – Pumice
Improves wetting

CLEANSING WITH PUMICE

CLEANED TEETH ISOLATED AND
READY FOR ETCHING

APPLICATION OF ETCHANT WITH
SMALL COTTON WOOL.

WASH ETCHED SURFACES
QUICKLY-20 SECONDS.

APPLY RESIN TO PREPARED ENAMEL
SURFACES.

APPLY RESIN TO THE BRACKET BASE

APPLY BONDING COMPOSITE
MATERIAL TO THE BRACKET BASE.

PLACING BRACKET ON TOOTH.

PROBE USED TO CHECK THE BRACKET
POSITION TO THE LONG AXIS OF TOOTH

BRACKETS IN POSITION.

Self – etch adhesive system

EXPOSES ENAMEL
RODS
PENETRATES
INTO THE
EXPOSED RODS
ETCHANT PRIMERS
METHACRYLATE BASE
BIFUNCTIONAL

Etch and deposit the primer
simultaneously
With this procedural sequence , it is
likely that the under filling of the
inorganic depleted zones will not
occur.
1 unit contains enough material for one
arch.

Etching depth & the resin
penetration depth are identical
Can be used for metal & ceramic
brackets.
It is a hydrophilic primer-
tolerates both moist & wet
conditions.

TRANSBOND PLUS – “SEP”

STEP -1

STEP -2

STEP-3

STEP- 4

STEP - 5

STEP-6

STEP-7

STEP-8

STEP- 9

Moisture Insensitive Primer
 Bonding can be done in the presence of
Moist environment.
 Requires moisture for the initiation of
polymerization.
MIP,s
Arndt kloche et. al. Angle orthodontist
2003 August.
Hydrophilic primer – from 3rd generation

Why Moisture control is
important?
 Surface energy reduced – less favourable
for bonding
 Porosities are plugged – reduced no of
tags
 Difficult anatomical areas
 2nd molar
 Lingual surfaces of lower teeth
 Partially erupted teeth
 Surgically exposed teeth

Commercially used MIPs
1. Transbond
2. Assure
Composition of Transbond
- Ethyl alcohol 30-40% ( Solvent )
- Bis-GMA

- HEMA – Hydroxy ethyl methacrylate
( main Hydrophilic component )
- CDMA – Citric acid
( allows greater cross linking )
- GDMA – Diluent + hydrophilic monomer
/ Same function as CDMA
/ The Hydrophilic monomer takes
Oral fluid & so fluoride uptake
- Acidic Co-polymer
/ Greater cross linkingwww.indiandentalacademy.com

-CPQ / Amine
-Photo initiator
- H2O - Solvent
( Water normally interferes with
adhesive if not removed.
But in Transbond, Water induces
Partial ionization of Carboxyl groups
& an inert dilution effect without
Activating any setting mechanism )

Studies
 Wet Conditions
Higher bond strength with MIP in
1 & 24 hours
 Dry Conditions
Conventional primer showed
higher strength in 1 & 24 hours
/ Robert A Miller ( Orthodontic perspectives, 1998)
/ Ramkumar Grandhi et al ( orthodon dentofacial orthop, 2001)

THERE ARE OCCASIONS WHERE
IT IS DESIRED TO INCREASE THE
BOND STRENGTHS OF NO MIX-
ADHESIVES.
•NON COMPLAINT PATIENTS
•HYPOCALCIFIED TOOTH
•FLOUROSED ENAMEL

ADHESION PROMOTORS
Bond chemically to metal Intermediate resins
4-META
10-MDP
Sun Medical,s Superbond C&B
ALL-BOND2
Reliance metal primer

FLUORIDE RELEASING ADHESIVES
FLUORISED IONS CAN BE SUBSTITUTED
FOR HYDROXY GROUPS OF
HYDROXYAPATITE AND THESE
FLUORISED TEETH ARE MORE RESISTANT
TO DENTAL CARIES.
RMGIC-FUJI ortho LC
PMCR-Transbond XT,3M s

ADHESIVE PRECOATED BRACKETS
(1992)
UNITEK /3M
COOPER et al
Consistent quality and quantity of adhesive
Reduced waste
Easier clean up
Same composition as in
transbond adhesive

ADHESIVE PRECOATED
BRACKETS
 Reduced Chair time
 Individual packaging- aids
identification and orientation
 Improved Cross-infection control

“APC” BRACKETS

PICK
PLACE CURE

Crystal growth technique.
/ Aim – to achieve micromechanical Crystalline
retentive surface on the enamel
( J Dent Research , Smith & Cartz, 1973 )
AVOIDING DAMAGE OF ACID ETCH TECHNIQUE

 Adding Gypsum, Lithium Salt, Potassium,
Sulphate salts – with basic solution
 Lithium Salt – better bond strength
Result – dense growth of needle shaped
crystals – “Spherulitic pattern”
/ Material – Polyacrylic acid solution containing
residual sulfate ion

OTHER BRACKET BONDING
SURFACES.
CERAMIC VARIETIES
GOLD
AMALGAM
VENEERS

DORON HARARI et al (AJO) 2003
(BIFUNCTIONAL MOLECULE)
Porcelain facets Adhesives
BONDING TO NON ENAMEL SURFACES
“PORCELAIN”
BONDING OF CERAMIC BRACKETS
MECHANICAL RETENTION OF ADHESIVE TO BRACKET
BASE
PREPARING THE PORCELAIN SURFACE
SILANE COUPLING AGENT
9.6%“HF” gels -2-4 minutes are used for etching
porcelain surfaceswww.indiandentalacademy.com

BONDING TO CERAMIC
RESTORATIONS
Fine diamond bur
Sandblasting
Micro-etching with alumino
silicates
5%HCL
Silica coating
Surface conditioning methods

Buyukyilmaz T AND Zachrisson (1998)
ANGLE ORTHODONTIST
In bonding to gold intra oral sandblasting
is superior to roughening with
diamond bur
Tin plating improves bond strengths but only
marginally . This procedure is not
recommended by the FDA and hence not
recommended for orthodontic purposes.
BONDING TO GOLD

BONDING TO AMALGAM
Intra-oral sandblasting for 2-4
seconds at a distance of 10mm.
Use a META intermediate resin
with a short curing time such
as reliance metal primer.

BONDING TO VENEERS
Kao and johston(1991)journal of prosthetic
dentistry.
Reported fracture incidence on debonding
orthodontic brackets from porcelain veneers
Lee –knight et al (1991)AJO
IT may be worth using a ceramic reinforced
resin bracket , such as ormco spirit or GAC
Elan , on veneers as these brackets are
extremely easy to debond.www.indiandentalacademy.com

Conclusion
/ Two primary strategies – Total etch & self etch
/ Both has advantages & disadvantages
/ Total etch – the only adhesive system with long term
data to support
/ Profession moving towards Self etch or all-in-one systems
/ Clinical success of bonding – in the hands of the clinician

ADHESIVES CAN BE
CLASSIFIED ACCORDING
TO
TOLERANCE OF MOISTURE
BANDING (or) BONDING
METHOD OF CURING
METHOD OF DISPENSING

ACCORDING TO THE METHOD OF DISPENSING
PASTE /PASTE SYSTEMS SINGLE PASTE (OR)NO MIX
ADHESIVES (Syringe) Light Cured
Initiator Activator
Benzoyl
peroxide
Tertiary
amine
U-V Light Visible Light
Eg: Chemically activated
resins
Eg: Light activated Composite
resins
Benzoyn
Methyl Ether
Camphoroquinone
(diketone)

Delport & grobler (1988)
Odegaard & segner (1988)
Bradburn & ponder(1992)
AJO
Little difference in the bond
strength between paste/paste &
no mix adhesives.

According to tolerance of moisture
HYDROPHOBIC e.g./ conventional BIS-GMA
These adhesives require etching and absolute
dry environment
HYDROPHILLIC e.g./GIC’S RMGIC’S
Achieves chemical adhesion without etching
and tolerates a little moisture
According to bishara et al (1997) AJO –
etching is required for bond strength.

Multicure
Resin modified -3M UNITEK
BANDING ADHESIVES

ACCORDING TO METHOD OF
CURING
CHEMICALCURED
e.g Fuji I(conventional GIC)
LIGHT CURED
e.g Transbond XL
DUAL CURE
e.g Reliance phase II dualwww.indiandentalacademy.com

POLYMERIZATION:
Chemical cure in 4 minutes by light in 30 seconds.
The material can be “SNAP SET” in 10 sec by light
cure and then allowed to cure chemically.
DUAL CURE
CHEMICAL CURE + LIGHT CURE
e.g. reliance phase II dual cure.

ADVANTAGES
COMMAND SETTING
EXTENDED WORKING TIME
Smith & Shivpuja (1993)AJO
Evaluated dual cure adhesives and
gave similar bond strengths to chemically
cured and light cured materials.

LASER
(Light Amplification of stimulated
emission of Radiation)
Von Praun Holfer and Arbell, Angle Orthodontist, 1993
Nd:YAG ( Neodymium Ytrium Aluminium Garment
Laser) - to etch Enamel
/ Conversion of Light energy to thermal energy
/ Thermally induced changes within Enamel to a
Depth of 16 to 20 microns

ADVANTAGES
1)Esthetically superior
2)Faster and simpler
Less discomfort for the patient
Arch length is not increased by band
material and no band spaces to close
at the end of treatment .
Better access for cleaning
Mesiodistal enamel reduction is
possible during treatment.www.indiandentalacademy.com

Disadvantages
1)However a bonded bracket has a weaker
attachment than a cemented band .
2)Better oral hygiene is not guaranteed
especially if excess adhesive extends
beyond the bracket base.
3)Rebonding a loose bracket requires more
preparation than rebonding a loose band

FOUR MECHANISMS OF
RESIN ADHESION TO
THE TOOTH
STRUCTURE

MECHANICAL
DIFFUSION
ADSORPTION
A COMBINATION

DIFFUSION:
PRECIPITATION OF SUBSTANCES ON
THE TOOTH SURFACES TO WHICH RESIN
MONOMERS CAN BOND MECHANICALLY (OR)
CHEMICALLY.
MECHANICAL:
PENETRATION OF RESIN &
FORMATION OF RESIN TAGS WITHIN THE
TOOTH SURFACE.

COMBINATION:
OF THE PREVIOUS THREE
MECHANISMS.
ADSORPTION:
CHEMICAL BONDING TO THE
INORGANIC COMPONENT (HYDROXY-APATITE) OR
ORGANIC COMPONENT MAINLY TYPE I OF
COLLAGEN TOOTH STRUCTURE.

Fluoride compared in our department
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