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INDIRECT
BONDING
Introduction
Tooth movement is made
possible by an orthodontist by
applying an optimal force.
Archwires,loops,springs,elastics,
etc- rigid attachment-bracket
Bands or bonds
Bonding – several advantages and
disadvantages
Advantages -
1.esthetic superiority
2.faster and simpler
3.less discomfort to the patient
4.arch length is not increased
 Bonds are more hygienic than
bands
 Mesiodistal enamel reduction
is possible
 Interproximal areas are
accessible for comp buildups
 Caries risk under loose bands
is eliminated
 No band spaces are left behind
 No large inventory of bands
 Lingual brackets, invisible
braces
 Brackets may be recycled
further reducing cost
DisadvantagesDisadvantages
 Weaker attachment
 Gingival problems
 The protection against well
contoured bands is absent
 Rebonding a loose bracket
 Debonding is more time
consuming
Acid etch bonding technique
Acid pretreatment-85%
phosphoric acid-1955-Buonocore
1965-epoxy resin-Newman
1968-smith poly acrylate
1970-several articles
Review
The most widely used resin,
commonly referred to as Bowen’s
resin was designed to improve
bond strength and increase
dimensional stability by cross
linking
The indirect bonding
technique was introduced
by Dr. Silverman and
Cohen in 1972 AJO
Types of bonding
1.Indirect bonding
2.Direct bonding -
a. chemical cured
b.light cured composite
c.glass ionomer cement
With the indirect bonding
technique, brackets fixed to the
tooth in the working casts and
then transferred to the patients
mouth with the help of an
impression tray which is usually
made of silicone
The bonding procedure in short
1. cleaning
2. enamel conditioning
3. sealing
4. bonding
a. transfer
b. positioning
c. fitting
d. removal of excess
Cleaning
pumice- plaque and organic
pellicle
rubber cup or polishing brush
bristle brush – more effective
but has certain disadvantages
Enamel conditioning
A. moisture control
After pumice-salivary control and dry
working field 1.cheek
retractors 2.saliva
ejectors 3.tongue
guards with bite blocks
4.salivary duct obstructers [dri-angles
–parotid]
5. Cotton or gauze rolls
6. antisialogogues-
banthine,probanthine,
atropine sulphate etc
..both tablets and
injections ..PB inj are no
longer advised
..antisialogogues are generally not
 banthine tab-50mgs/100lb-15
minutes before bonding
 only under supervision of the
patients physician
 contact lenses should be
removed-until next day
B.enamel pretreatment
Conditioning solution[37%
phosphoric acid for 15-60 sec]
Etchant rinsed off
Salivary contamination-not
allowed. If it occurs water spray or
re-etch for a few seconds; the
patient must not rinse
Next the teeth are
thoroughly dried with
moisture and oil free
source to obtain the well
known dull, frosty
appearance
Good bond strength is
dependent on
1.avoiding moisture
contamination
2.achieving undisturbed
setting of bonding adhesive
3.use of a strong adhesive
Sealing
Nothing but an intermediate
resin
Teeth dry-thin layer of sealant
Foam pellet or brush with a single
gingivo- incisal stroke The
sealant coating should be thin and
even
Bonding
The easiest method of bonding..
1. transfer
2. positioning
3. fitting
4. removal of excess
 a slight bit of excess is
necessary
 excess adhesive should be
removed
 excess adhesive when not
removed-discolored
 the first three procedures are
the same for direct and indirect
bonding techniques
Indirect
bonding..
Originally described by Dr.
Silverman and Cohen
several techniques-the brackets
are attached to the teeth on patients
model, transferred to the mouth with
some sort of tray to which the
brackets get embedded and then
bonded simultaneously
The clinical procedure
The techniques differ -
..the way brackets are attached
to the model
..type of transfer tray
..adhesive or sealant used
..the way transfer is removed
An over view of the indirect
bonding technique
a. Take an impression and pour
with stone. Model-dry. Long axis
and occlusal height
b. Select brackets
c. Apply water soluble adhesive
d. Position the brackets
Indirect bonding
Indirect bonding
e. Mix putty silicone and press it
onto the cemented brackets
f. Immerse model and tray in hot
water. Remove any remaining
adhesive
g. Trim the silicone tray and
mark the midline
h. Prepare the patients teeth
i. Load adhesive-bracket base
Indirect bonding
Indirect bonding
j. Seat the tray on the prepared
arch-3 minutes
k.Remove tray after 10 min. tray
must be cut longitudinally or
transversely
l. Complete bonding by careful
removal of excessive flash
Indirect bonding
Indirect bonding
Indirect bonding
Modifications
Several methods – bonding
resins, sticky wax etc
Dr. Michael.D.Simmons-1978-
April-JCO-caramel candy softened
and preloaded in syringe.
Small amount of caramel is
warmed to approx 500
c –loaded
preloaded syringe- 500
c-5min
Indirect bonding
Indirect bonding
A small amount is squeezed
onto each tooth to be bonded. The
brackets are then held with cotton
pliers warmed slightly in Bunsen
burner and then placed on the teeth.
Rest of the procedure is similar
Disadvantage of sticky wax.
Advantage of caramel candy
Indirect bonding
Indirect bonding
Indirect bonding
2.Since one of the major
difficulties with indirect bonding…
double tray technique-
Elliott.M.Moskowitz and Douglas
Knight-1996 may JCO
Thermal cured composite
[unlimited working time] and vinyl
polysiloxane [flexible but highly
accurate under tray]
Apply thermacure composite to
the mesh pad of each bracket-cast.
Cast in heated oven -15 min at
325o
F. After cooling remove.
Apply vinyl polysiloxane over
thermally cured brackets.
Adapt the vacuum formed Essix
clear thermoplastic material over the
cast, brackets and under tray comp.
Indirect bonding
Indirect bonding
Indirect bonding
Chair side bonding
procedure.
1. Lightly abrade adhesive-
diamond bur or simply scrape
2. Isolate, etch, rinse and dry as
usual.
3. Apply bonding agent-tooth
and adhesive –bracket bases and
Indirect bonding
Indirect bonding
4. Remove the clear over tray.
5. Tease the flexible under tray-
explorer or scaler without
dislodging the brackets.
Advantages…
The under trays are accurate,
stable and compact and will not
dislodge the brackets from teeth
when removed
Indirect bonding
Indirect bonding
3. Light cured indirect
bonding.
JCO-1998-Aug-Michael Read
Transfer tray-silicone based,
addition cured elastomer [Memosil]-
stiff enough but easily removed .
1. Coat labial surface of teeth
with thin layer of Poly vinyl acetate
Indirect bonding
2. Brush a thin layer of unfilled
resin onto each bracket base-light
cure it for 30 sec.
3. Add the filled composite to
bracket bases-brackets on the casts.
4. Cure each bracket-30 sec
from occlusal and 30 sec form
gingival.
5. Adapt the transfer tray.
6. Soak the tray in cold water for
20 min.
7. Etch the teeth to be bonded as
usual. Paint thin layer of unfilled
resin over the etched enamel and
over the cured composite
8. Place the transfer tray in the
mouth and light cure each tooth for
30 sec.
Indirect bonding
4.Thermal cured, fluoride releasing
indirect bonding system.
JCO-1998-Feb-Sinha,Nanda
Modification of previously
described IB with Therma cure.
Failure to remove excess
adhesive-accumulation of plaque.
Even when excess plaque is
reasonably removed-deposits .
The only modification in
this technique is we add
Maxicure sealants A and B. This
sealant contains hydrofluoric
acid in its monomer thereby
preventing caries
5. Adhesive precoated
brackets
JCO-1993-March by Ronald B
Cooper.
Except for the APC brackets the
rest of the procedure is similar
6. Sondhi indirect
adhesive
AJO-April-1999
why a new adhesive
A new resin with higher
viscosity [fine particle fumed
silica filler]
Setting time-30 sec
Complete curing in 2 min
The lab procedure
Working models
Separating medium-1 hour
APC brackets-removed
directly from the sealed blister
If non coated brackets-
Transbond XT light cured adhesive-
placed on mesh pad
Indirect bonding
Indirect bonding
Indirect bonding
Remove the excess cement.
Cure the resin
Significant undercut areas are
blocked with wax.
Bonding trays are formed-either
double tray technique or with
silicone transfer material.
Cure it again to ensure that any
uncured resin is cured
Indirect bonding
The bonding procedure
Initial preparations
Micro-etching unit – sand blast
Contamination of custom
adhesive bases –acetone and air dry
MIP is optional
Sondhi Indirect adhesive – resin
A[tooth surface] and Resin B[resin
pads]
Indirect bonding
Indirect bonding
Position the tray over the teeth –
equal pressure- 30 sec- 2 min
Remove Tray with scaler- from
lingual to buccal
Repeat the procedure for the
opposite arch
Main indication -
lingual
Early 1970s – Dr Craven Kurz –
Assistant Professor of occlusion and
gnathology
Plastic lee fischer brackets –ant. and
metal for post. Shearing
force – debonding Uncomfortable to
the tongue
Turning point – ant.
Inclined plane – shearing
force to intrusive force –
intrusive and labial
Indirect bonding
Difficulties and modificationsDifficulties and modifications
 Tissue irritation and speechTissue irritation and speech
earlier vs current bracketsearlier vs current brackets
smooth exteriors – normalsmooth exteriors – normal
activityactivity
 Gingival impingementGingival impingement
earlier-broad bonding base-earlier-broad bonding base-
adequate oral hygiene,selfadequate oral hygiene,self
cleansing-compromisedcleansing-compromised
The bases now-incisally andThe bases now-incisally and
mesio distally widemesio distally wide
Additionally gingival hooksAdditionally gingival hooks
were redesigned so that theywere redesigned so that they
are shorter and also away fromare shorter and also away from
the gingivathe gingiva
Occlusal interferenceOcclusal interference
 Predominant problem-shearingPredominant problem-shearing
force- upper ant bracketsforce- upper ant brackets
 Redesigned with inclined planeRedesigned with inclined plane
 Location of inclined plane..Location of inclined plane..
Base pad adaptation
Accurate contour of base pad
not only improves the retentive
capability but also the accuracy of
bracket placement – quality of
treatment
Appliance prescriptionAppliance prescription
 Early 1970s – Andrews –Early 1970s – Andrews –
straight wirestraight wire
 In-out varied dramatically-toIn-out varied dramatically-to
adjust this purely by bracketadjust this purely by bracket
design ?design ?
 First order bends – where?First order bends – where?
Wire placement
Access for wire
placement is limited from
lingual aspect.
Redesigned – widening
the mesial opening
Indirect bonding
Gingival hooks
They are an integral part
of lingual appliance therapy.
Original hooks were
larger-redesigned – smaller
and away from gingival
margin
Generation of brackets
First generation - 1976
Flat maxillary Occlusal bite
plane.
Premolar brackets were low
profile.
No hooks on any bracket
Indirect bonding
Second generation- 1980.
Hooks were added to all
canine brackets.
Third generation – 1981.
Hooks were added to all
anterior and premolar brackets
Indirect bonding
Indirect bonding
Fourth generation – 1982-84.
Low profile anterior bite
plane.
Hooks were optional –
depending upon treatment plan
and hygiene requirements
Indirect bonding
Fifth generation – 1985-86
Inclined plane – more pronouncedInclined plane – more pronounced
Greater labial torque – maxGreater labial torque – max
incisorsincisors
Hooks were optionalHooks were optional
Sheath for TPA was availableSheath for TPA was available
Canine inclined plane-bi beveledCanine inclined plane-bi beveled
Indirect bonding
Indirect bonding
Sixth generation–1987–90.
 Inclined plane – square shapedInclined plane – square shaped
 TPA sheath was optionalTPA sheath was optional
 Hinge cap attachment forHinge cap attachment for
molarmolar
Indirect bonding
Seventh generation-1990Seventh generation-1990
0nwards0nwards
 Inclined plane is heart shapedInclined plane is heart shaped
 Premolar brackets – widerPremolar brackets – wider
mesio distally with shortermesio distally with shorter
hookshooks
 All hooks have greater recess –All hooks have greater recess –
ease of ligationease of ligation
Indirect bonding
Situations where lingual
therapy is advantageous -
1. Intrusion.
2. Max arch expansion .
3. Max molar distalisation
Intrusion
Brackets closer to c res.
Intrusive forces closer to c res.
Bite plane effect – active
intrusion on ant and passive
extrusion of post
Indirect bonding
Maxillary arch expansion
although not clearly
understood,clinically…
possible reasons--
1. Centrifugal force
2. Thickness of brackets
3. Shorter IB span could
also be a possible cause
Maxillary molar
distalisation.
Lingual attachments are
closer to the c res.of the molar –
which is found corresponding to
the palatal root of molar
Laboratory techniques.
1. CLASS system.
2. TARG system.
3. HIRO system.
The CLASS system
1. Accurate impressions –
die stone.
2. Duplicate the cast .
3. Prepare a diagnostic set-up
– arch form,ant. Tip torque,
alignment etc
4. Clean the lingual surface –
apply separating medium
Indirect bonding
Indirect bonding
6. Mount the model on model
holder with Occlusal plane
parallel to horizontal reference
plane.
7. Brackets are attached to the
set-up cast – two part heavy body
composite.
8. Transfer brackets to
malocclusion cast – light cured
Indirect bonding
9. Brackets removed from
set-up model and attached to
malocclusion model – water
soluble adhesive.
10. Hot oven for 1 hour.
11. Remove the light
cured resin and fabricate
transfer – biostar machine
12. Place the cast in warm
water for 30 min – remove the tray
13. Abrade the composite
slightly.
14. Trays are labeled and
placed in a clean sealed plastic bag
The TARG system.
Torque angulation reference
guide – ORMCO 1984.
Capable of positioning the
brackets at specific heights.
Consists of a torque gauge -
middle of labial surface.
A torque blade is used to orient
the brackets
Indirect bonding
Indirect bonding
The horizontal blade of TARG
gauge – bracket slot – moved
towards varnished model.
The gap – packed with a filled
resin – custom made bracket base
which accurately fits the lingual
surface is made.
Transfer tray fabricated
Indirect bonding
Indirect bonding
AdvantagesAdvantages
 Permits more accuratePermits more accurate
placement of bracketsplacement of brackets
 Decreases chair side timeDecreases chair side time
 Less patient discomfortLess patient discomfort
 Esthetically more pleasingEsthetically more pleasing
 Incidence of caries is lessIncidence of caries is less
 Avoiding band fitting onAvoiding band fitting on
posterior teethposterior teeth
 Improved ability to bondImproved ability to bond
posterior teethposterior teeth
DisadvantagesDisadvantages
 Technique sensitiveTechnique sensitive
 Additional set of impressionsAdditional set of impressions
neededneeded
 Posterior attachments morePosterior attachments more
likely to fail if the patientlikely to fail if the patient
chews ice etcchews ice etc
 Removal of adhesive is moreRemoval of adhesive is more
difficult and time consumingdifficult and time consuming
 Risk for adhesive deficiencies isRisk for adhesive deficiencies is
greatergreater
 Failure rates seems to be slightlyFailure rates seems to be slightly
higherhigher
 Extensive laboratory workExtensive laboratory work
requiredrequired
 Risk of debonding is highRisk of debonding is high
Conclusion
when the laboratory and the
clinical procedures are strongly
adhered,indirect bonding is
undoubtedly a valuable technique. It
proves itself by saving chair side
time which is the most valuable for
a practitioner.
If not for the labial technique,it
is definitely a boon for the
lingual operating system
Thank you !

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Indirect bonding

  • 2. Introduction Tooth movement is made possible by an orthodontist by applying an optimal force. Archwires,loops,springs,elastics, etc- rigid attachment-bracket
  • 3. Bands or bonds Bonding – several advantages and disadvantages Advantages - 1.esthetic superiority 2.faster and simpler 3.less discomfort to the patient 4.arch length is not increased
  • 4.  Bonds are more hygienic than bands  Mesiodistal enamel reduction is possible  Interproximal areas are accessible for comp buildups  Caries risk under loose bands is eliminated
  • 5.  No band spaces are left behind  No large inventory of bands  Lingual brackets, invisible braces  Brackets may be recycled further reducing cost
  • 6. DisadvantagesDisadvantages  Weaker attachment  Gingival problems  The protection against well contoured bands is absent  Rebonding a loose bracket  Debonding is more time consuming
  • 7. Acid etch bonding technique Acid pretreatment-85% phosphoric acid-1955-Buonocore 1965-epoxy resin-Newman 1968-smith poly acrylate 1970-several articles Review
  • 8. The most widely used resin, commonly referred to as Bowen’s resin was designed to improve bond strength and increase dimensional stability by cross linking
  • 9. The indirect bonding technique was introduced by Dr. Silverman and Cohen in 1972 AJO
  • 10. Types of bonding 1.Indirect bonding 2.Direct bonding - a. chemical cured b.light cured composite c.glass ionomer cement
  • 11. With the indirect bonding technique, brackets fixed to the tooth in the working casts and then transferred to the patients mouth with the help of an impression tray which is usually made of silicone
  • 12. The bonding procedure in short 1. cleaning 2. enamel conditioning 3. sealing 4. bonding a. transfer b. positioning c. fitting d. removal of excess
  • 13. Cleaning pumice- plaque and organic pellicle rubber cup or polishing brush bristle brush – more effective but has certain disadvantages
  • 14. Enamel conditioning A. moisture control After pumice-salivary control and dry working field 1.cheek retractors 2.saliva ejectors 3.tongue guards with bite blocks 4.salivary duct obstructers [dri-angles –parotid]
  • 15. 5. Cotton or gauze rolls 6. antisialogogues- banthine,probanthine, atropine sulphate etc ..both tablets and injections ..PB inj are no longer advised ..antisialogogues are generally not
  • 16.  banthine tab-50mgs/100lb-15 minutes before bonding  only under supervision of the patients physician  contact lenses should be removed-until next day
  • 17. B.enamel pretreatment Conditioning solution[37% phosphoric acid for 15-60 sec] Etchant rinsed off Salivary contamination-not allowed. If it occurs water spray or re-etch for a few seconds; the patient must not rinse
  • 18. Next the teeth are thoroughly dried with moisture and oil free source to obtain the well known dull, frosty appearance
  • 19. Good bond strength is dependent on 1.avoiding moisture contamination 2.achieving undisturbed setting of bonding adhesive 3.use of a strong adhesive
  • 20. Sealing Nothing but an intermediate resin Teeth dry-thin layer of sealant Foam pellet or brush with a single gingivo- incisal stroke The sealant coating should be thin and even
  • 21. Bonding The easiest method of bonding.. 1. transfer 2. positioning 3. fitting 4. removal of excess
  • 22.  a slight bit of excess is necessary  excess adhesive should be removed  excess adhesive when not removed-discolored  the first three procedures are the same for direct and indirect bonding techniques
  • 24. Originally described by Dr. Silverman and Cohen several techniques-the brackets are attached to the teeth on patients model, transferred to the mouth with some sort of tray to which the brackets get embedded and then bonded simultaneously
  • 25. The clinical procedure The techniques differ - ..the way brackets are attached to the model ..type of transfer tray ..adhesive or sealant used ..the way transfer is removed
  • 26. An over view of the indirect bonding technique a. Take an impression and pour with stone. Model-dry. Long axis and occlusal height b. Select brackets c. Apply water soluble adhesive d. Position the brackets
  • 29. e. Mix putty silicone and press it onto the cemented brackets f. Immerse model and tray in hot water. Remove any remaining adhesive g. Trim the silicone tray and mark the midline h. Prepare the patients teeth i. Load adhesive-bracket base
  • 32. j. Seat the tray on the prepared arch-3 minutes k.Remove tray after 10 min. tray must be cut longitudinally or transversely l. Complete bonding by careful removal of excessive flash
  • 36. Modifications Several methods – bonding resins, sticky wax etc Dr. Michael.D.Simmons-1978- April-JCO-caramel candy softened and preloaded in syringe. Small amount of caramel is warmed to approx 500 c –loaded preloaded syringe- 500 c-5min
  • 39. A small amount is squeezed onto each tooth to be bonded. The brackets are then held with cotton pliers warmed slightly in Bunsen burner and then placed on the teeth. Rest of the procedure is similar Disadvantage of sticky wax. Advantage of caramel candy
  • 43. 2.Since one of the major difficulties with indirect bonding… double tray technique- Elliott.M.Moskowitz and Douglas Knight-1996 may JCO Thermal cured composite [unlimited working time] and vinyl polysiloxane [flexible but highly accurate under tray]
  • 44. Apply thermacure composite to the mesh pad of each bracket-cast. Cast in heated oven -15 min at 325o F. After cooling remove. Apply vinyl polysiloxane over thermally cured brackets. Adapt the vacuum formed Essix clear thermoplastic material over the cast, brackets and under tray comp.
  • 48. Chair side bonding procedure. 1. Lightly abrade adhesive- diamond bur or simply scrape 2. Isolate, etch, rinse and dry as usual. 3. Apply bonding agent-tooth and adhesive –bracket bases and
  • 51. 4. Remove the clear over tray. 5. Tease the flexible under tray- explorer or scaler without dislodging the brackets. Advantages… The under trays are accurate, stable and compact and will not dislodge the brackets from teeth when removed
  • 54. 3. Light cured indirect bonding. JCO-1998-Aug-Michael Read Transfer tray-silicone based, addition cured elastomer [Memosil]- stiff enough but easily removed . 1. Coat labial surface of teeth with thin layer of Poly vinyl acetate
  • 56. 2. Brush a thin layer of unfilled resin onto each bracket base-light cure it for 30 sec. 3. Add the filled composite to bracket bases-brackets on the casts. 4. Cure each bracket-30 sec from occlusal and 30 sec form gingival. 5. Adapt the transfer tray.
  • 57. 6. Soak the tray in cold water for 20 min. 7. Etch the teeth to be bonded as usual. Paint thin layer of unfilled resin over the etched enamel and over the cured composite 8. Place the transfer tray in the mouth and light cure each tooth for 30 sec.
  • 59. 4.Thermal cured, fluoride releasing indirect bonding system. JCO-1998-Feb-Sinha,Nanda Modification of previously described IB with Therma cure. Failure to remove excess adhesive-accumulation of plaque. Even when excess plaque is reasonably removed-deposits .
  • 60. The only modification in this technique is we add Maxicure sealants A and B. This sealant contains hydrofluoric acid in its monomer thereby preventing caries
  • 61. 5. Adhesive precoated brackets JCO-1993-March by Ronald B Cooper. Except for the APC brackets the rest of the procedure is similar
  • 62. 6. Sondhi indirect adhesive AJO-April-1999 why a new adhesive A new resin with higher viscosity [fine particle fumed silica filler] Setting time-30 sec Complete curing in 2 min
  • 63. The lab procedure Working models Separating medium-1 hour APC brackets-removed directly from the sealed blister If non coated brackets- Transbond XT light cured adhesive- placed on mesh pad
  • 67. Remove the excess cement. Cure the resin Significant undercut areas are blocked with wax. Bonding trays are formed-either double tray technique or with silicone transfer material. Cure it again to ensure that any uncured resin is cured
  • 69. The bonding procedure Initial preparations Micro-etching unit – sand blast Contamination of custom adhesive bases –acetone and air dry MIP is optional Sondhi Indirect adhesive – resin A[tooth surface] and Resin B[resin pads]
  • 72. Position the tray over the teeth – equal pressure- 30 sec- 2 min Remove Tray with scaler- from lingual to buccal Repeat the procedure for the opposite arch
  • 73. Main indication - lingual Early 1970s – Dr Craven Kurz – Assistant Professor of occlusion and gnathology Plastic lee fischer brackets –ant. and metal for post. Shearing force – debonding Uncomfortable to the tongue
  • 74. Turning point – ant. Inclined plane – shearing force to intrusive force – intrusive and labial
  • 76. Difficulties and modificationsDifficulties and modifications  Tissue irritation and speechTissue irritation and speech earlier vs current bracketsearlier vs current brackets smooth exteriors – normalsmooth exteriors – normal activityactivity  Gingival impingementGingival impingement earlier-broad bonding base-earlier-broad bonding base- adequate oral hygiene,selfadequate oral hygiene,self cleansing-compromisedcleansing-compromised
  • 77. The bases now-incisally andThe bases now-incisally and mesio distally widemesio distally wide Additionally gingival hooksAdditionally gingival hooks were redesigned so that theywere redesigned so that they are shorter and also away fromare shorter and also away from the gingivathe gingiva
  • 78. Occlusal interferenceOcclusal interference  Predominant problem-shearingPredominant problem-shearing force- upper ant bracketsforce- upper ant brackets  Redesigned with inclined planeRedesigned with inclined plane  Location of inclined plane..Location of inclined plane..
  • 79. Base pad adaptation Accurate contour of base pad not only improves the retentive capability but also the accuracy of bracket placement – quality of treatment
  • 80. Appliance prescriptionAppliance prescription  Early 1970s – Andrews –Early 1970s – Andrews – straight wirestraight wire  In-out varied dramatically-toIn-out varied dramatically-to adjust this purely by bracketadjust this purely by bracket design ?design ?  First order bends – where?First order bends – where?
  • 81. Wire placement Access for wire placement is limited from lingual aspect. Redesigned – widening the mesial opening
  • 83. Gingival hooks They are an integral part of lingual appliance therapy. Original hooks were larger-redesigned – smaller and away from gingival margin
  • 84. Generation of brackets First generation - 1976 Flat maxillary Occlusal bite plane. Premolar brackets were low profile. No hooks on any bracket
  • 86. Second generation- 1980. Hooks were added to all canine brackets. Third generation – 1981. Hooks were added to all anterior and premolar brackets
  • 89. Fourth generation – 1982-84. Low profile anterior bite plane. Hooks were optional – depending upon treatment plan and hygiene requirements
  • 91. Fifth generation – 1985-86 Inclined plane – more pronouncedInclined plane – more pronounced Greater labial torque – maxGreater labial torque – max incisorsincisors Hooks were optionalHooks were optional Sheath for TPA was availableSheath for TPA was available Canine inclined plane-bi beveledCanine inclined plane-bi beveled
  • 94. Sixth generation–1987–90.  Inclined plane – square shapedInclined plane – square shaped  TPA sheath was optionalTPA sheath was optional  Hinge cap attachment forHinge cap attachment for molarmolar
  • 96. Seventh generation-1990Seventh generation-1990 0nwards0nwards  Inclined plane is heart shapedInclined plane is heart shaped  Premolar brackets – widerPremolar brackets – wider mesio distally with shortermesio distally with shorter hookshooks  All hooks have greater recess –All hooks have greater recess – ease of ligationease of ligation
  • 98. Situations where lingual therapy is advantageous - 1. Intrusion. 2. Max arch expansion . 3. Max molar distalisation
  • 99. Intrusion Brackets closer to c res. Intrusive forces closer to c res. Bite plane effect – active intrusion on ant and passive extrusion of post
  • 101. Maxillary arch expansion although not clearly understood,clinically… possible reasons-- 1. Centrifugal force 2. Thickness of brackets 3. Shorter IB span could also be a possible cause
  • 102. Maxillary molar distalisation. Lingual attachments are closer to the c res.of the molar – which is found corresponding to the palatal root of molar
  • 103. Laboratory techniques. 1. CLASS system. 2. TARG system. 3. HIRO system.
  • 104. The CLASS system 1. Accurate impressions – die stone. 2. Duplicate the cast . 3. Prepare a diagnostic set-up – arch form,ant. Tip torque, alignment etc 4. Clean the lingual surface – apply separating medium
  • 107. 6. Mount the model on model holder with Occlusal plane parallel to horizontal reference plane. 7. Brackets are attached to the set-up cast – two part heavy body composite. 8. Transfer brackets to malocclusion cast – light cured
  • 109. 9. Brackets removed from set-up model and attached to malocclusion model – water soluble adhesive. 10. Hot oven for 1 hour. 11. Remove the light cured resin and fabricate transfer – biostar machine
  • 110. 12. Place the cast in warm water for 30 min – remove the tray 13. Abrade the composite slightly. 14. Trays are labeled and placed in a clean sealed plastic bag
  • 111. The TARG system. Torque angulation reference guide – ORMCO 1984. Capable of positioning the brackets at specific heights. Consists of a torque gauge - middle of labial surface. A torque blade is used to orient the brackets
  • 114. The horizontal blade of TARG gauge – bracket slot – moved towards varnished model. The gap – packed with a filled resin – custom made bracket base which accurately fits the lingual surface is made. Transfer tray fabricated
  • 117. AdvantagesAdvantages  Permits more accuratePermits more accurate placement of bracketsplacement of brackets  Decreases chair side timeDecreases chair side time  Less patient discomfortLess patient discomfort  Esthetically more pleasingEsthetically more pleasing  Incidence of caries is lessIncidence of caries is less
  • 118.  Avoiding band fitting onAvoiding band fitting on posterior teethposterior teeth  Improved ability to bondImproved ability to bond posterior teethposterior teeth
  • 119. DisadvantagesDisadvantages  Technique sensitiveTechnique sensitive  Additional set of impressionsAdditional set of impressions neededneeded  Posterior attachments morePosterior attachments more likely to fail if the patientlikely to fail if the patient chews ice etcchews ice etc
  • 120.  Removal of adhesive is moreRemoval of adhesive is more difficult and time consumingdifficult and time consuming  Risk for adhesive deficiencies isRisk for adhesive deficiencies is greatergreater  Failure rates seems to be slightlyFailure rates seems to be slightly higherhigher
  • 121.  Extensive laboratory workExtensive laboratory work requiredrequired  Risk of debonding is highRisk of debonding is high
  • 122. Conclusion when the laboratory and the clinical procedures are strongly adhered,indirect bonding is undoubtedly a valuable technique. It proves itself by saving chair side time which is the most valuable for a practitioner.
  • 123. If not for the labial technique,it is definitely a boon for the lingual operating system Thank you !